Virtual reality ophthalmic surgical simulation as a feasibletraining and assessment tool: results of a multicentre studyTran D.B. Le,* MD; Feisal A. Adatia,{ MD, FRCSC; Wai-Ching Lam,{ MD, FRCSC

ABSTRACT N RESUME

Objective: To compare performance on the Eyesi surgical simulator by users with different levels of experience in ophthalmology.Design: Multicentre cross-sectional study.Participants: Four medical students, 4 ophthalmic medical technologist trainees, 36 ophthalmology residents, 3 fellows, and

18 staff ophthalmologists.Methods: Subjects were recruited at the 2007 Canadian Ophthalmological Society Meeting and in the departments of ophthalmology at the

University of Toronto, University of Ottawa, andUniversity ofWesternOntario. Subjects performed a standardized 20-minute session on theEyesi simulator. The protocol consisted of a practice trial in the anterior segment module, followed by 3 scored trials in the anterior forceps,antitremor, and capsulorhexis modules.

Results: In the forceps module, participants with greater experience achieved significantly higher total scores than those who were lessexperienced: staff ophthalmologists (GroupD)5 67.9 (SD18.4), senior residents and fellows (GroupC)5 67.6 (SD21.1), junior residents(Group B) 5 52.9 (SD 29.4), medical students and ophthalmic medical technologist trainees (Group A) 5 27.8 (SD 29.4)(p 5 0.011), with lower total task time (p 5 0.044) and fewer injuries to the cornea (p 5 0.001) and lens (p 5 0.026). In the antitremormodule, subjects inGroupD achieved significantly higher (p5 0.004) total scores (46.7, SD 21.6) thanGroupsC (45.8, SD 25.1), B (41.2,SD 29.4), and A (8.5, SD 9.2) with lower total task time (p 5 0.005) and fewer errors (p 5 0.003). In the capsulorhexis module there wasalso a positive correlation between experience and total scores achieved (p 5 0.065).

Conclusions: Subjects’ level of training is a reliable predictor of their performance on the Eyesi anterior forceps and antitremor modules(p , 0.05), indicating the modules’ construct validity.

Objet : Comparaison de la performance d’utilisateurs ayant differents niveaux d’experience en ophtalmologie avec le simulateurchirurgical Eyesi.

Nature : Etude transversale multicentre.Participants : Quatre etudiants en medecine, 4 technologues stagiaires en medecine ophtalmique, 36 residents en ophtalmologie,

3 associes et 18 ophtalmologistes patrons.Methodes : Les sujets ont ete recrutes au congres de 2007 de la Societe canadienne d’ophtalmologie et dans les departements d’ophtal-

mologie de l’Universite de Toronto, l’Universite d’Ottawa et l’Universite Western Ontario. Ils ont pratique une seance normale de20 minutes avec le simulateur Eyesi. Le protocole comportait un essai pratique dans le module du segment anterieur, suivi de 3 essaisnotes dans les modules des pinces anterieures, des anti-tremblement et du capsulorhexis.

Resultats : Dans le module des pinces, les participants qui avaient plus d’experience ont obtenu des notes significativement superieures acelles des moins experimentes : ophtalmologistes patrons (groupe D)5 67,9 (ET 18,4), residents seniors et associes (groupe C)5 67,6(ET 21,1), residents juniors (groupe B)5 52,9 (ET 29,4), etudiants en medecine et technologues stagiaires en medecine ophtalmique(groupeA)5 27,8 (ET 29,4) (p5 0,011), avecmoins de temps global de travail (p5 0,044) et moins de blessures a la cornee (p5 0,001) etau cristallin (p5 0,026). Dans le module anti-tremblement, les sujets du groupe D ont obtenu globalement des notes significativementsuperieures (p5 0,004) (46,7, ET 21,6) que les groupesC (45,8, ET 25,1), B (41,2, ET 29,4) et A (8,5, ET 9,2) avecmoins de temps globalde travail (p 5 0,005) et moins d’erreurs (p 5 0,003). Dans le module du capsulorhexis, il y avait aussi une correlation positive entrel’experience et l’ensemble des notes obtenues (p 5 0,065).

Conclusions : Le niveau de formation des sujets est un predicteur fiable de leur performance sur les modules des pinces anterieures etd’anti-tremblement de Eyesi (p , 0,05), indiquant la validite de construction des modules.

The training of ophthalmology residents involves super-vised graduated responsibility in the surgical discipline. Tominimize harm to patients and better prepare traineesfor surgery, residency programs are constantly seekingeffective and efficient tools to help trainees acquirerelevant skills outside of the operating room. Recently,high-fidelity, virtual reality simulators for ophthalmic

surgery have received much attention in the realm of sur-gical education.1,2 Virtual reality training has been exam-ined in nearly all branches of surgery,3–13 includingophthalmology.1,2,14–19 Currently, there are 2 commer-cially available ophthalmic simulators: Eyesi (VRmagic,Mannheim, Germany) and PhacoVision (Melerit Med-ical, Linkoping, Sweden).

From *the University of Toronto (ophthalmology resident), Toronto, Ont.;{Moorfields Eye Hospital (retina fellow), London, England; and {theDepartment of Ophthalmology, University of Toronto, Toronto, Ont.

Originally received Feb. 9, 2010. Final revision Mar. 14, 2010Accepted Mar. 24, 2010Available online Jan. 31, 2011

Correspondence to Wai-Ching Lam, MD, Toronto Western Hospital, 399Bathurst St., EW 6-432, Toronto, ON M5T 2S8; waiching.lam@utoronto.ca

Presented at the American Academy of Ophthalmology Joint Meeting,Atlanta, Ga., 2008; the Royal College of Physicians and Surgeons of CanadaInternational Conference on Residency Education – Simulation Summit,Ottawa, Ont., 2008; the World Ophthalmology Congress Meeting, HongKong, 2008; the Canadian Ophthalmological Society Annual Meeting &Exhibition, Whistler, B.C., 2008; and the AFMC Canadian MedicalEducation Conference, Montreal, Que., 2008.

Can J Ophthalmol 2011;46:56–60

doi:10.3129/i10-051

56 CAN J OPHTHALMOL—VOL. 46, NO. 1, FEBRUARY 2011

The Eyesi surgical simulator was first developed as avitreoretinal surgical training system. Rossi et al.16 havedemonstrated construct validity in the posterior segmentmembrane-peeling task, when experienced surgeons hadfewer errors than novice surgeons. VRmagic has furtherdeveloped the technology to allow for anterior segmenttraining. A small study looking at 12 residents and 3experienced anterior segment surgeons demonstrated con-struct validity in the forceps and antitremor modules.1

However, this study was limited by its small sample.Simulation technology for ophthalmology offers the

possibility of a new assessment and training modality.This new modality can help to prepare and determineresidents’ readiness to perform on live cases and thus serveto reduce trainees’ anxiety and, most importantly, surgicalrisks to patients. The goal of our study was to furtherexplore the construct validity of the Eyesi simulator in alarger-scale study.

METHODS

Subjects

Subjects were medical students, ophthalmology resi-dents, ophthalmic medical technologist (OMT) trainees,fellows, and staff ophthalmologists recruited by posteradvertisement at the 2007 Canadian OphthalmologicalSociety Annual Meeting. Additional trials were com-pleted at the University of Toronto in November 2007,the University of Ottawa in January 2008, and the Uni-versity of Western Ontario in August 2008; the subjectswere primarily residents. Participation was voluntary, andno enticements were used. Ethics approval was receivedfrom the Health Sciences Research Ethics Board at theUniversity of Toronto and the Ottawa Hospital ResearchEthics Board.Subjects were grouped according to their level of training:

medical students and OMT trainees (Group A), junior resi-dents (Group B), senior residents and fellows (Group C),and staff ophthalmologists (Group D).

Eyesi simulator

The multicentre, cross-sectional study was performedusing the Eyesi (VRMagic, software version 2.23). Theplatform includes a binocular microscope system thatrequires users to pan, zoom, and focus with a foot-pedalcontrol, as well as anterior segment modular heads withmodel eyes that appropriately pivot and rotate whenmanipulated. During the simulated surgery, users workwith handheld and foot-pedal activated devices designedto emulate various intraocular surgical instruments. Theprogram includes a tracking system that captures themovement of the instruments and eye, as well as the bio-mechanical reaction of the tissue. There is a also aninstructor station that allows for real time monitoring ofperformance, video replay and recording, manipulation of

instrument settings, and viewing and downloading of indi-vidual historical performance data.Each participant completed the study in a single simu-

lator session, with a limit of 20 minutes for task perfor-mance time. This study tested performance in 3 anteriorsegment modules. (i) The cataract forceps module requiresusers to grasp 6 objects and place them into a ‘‘basket.’’The outcome measures for this task were time to completethe task, incision stress, corneal or lens injury, and taskcompletion. The module is designed to train users to pre-cisely work in the 3-dimensional environment of theanterior chamber. (ii) The antitremor module requiresusers to move a small ball along a circular path using aninstrument simulating a surgical probe. The module isdesigned to train users to precisely pivot at the incisionand to control the instrument tip to create a capsulorhexis.Aside from time and incision stress, the outcome measuresfor this task included an out-of-tolerance percentage value(a measure of deviation from the given curvilinear path)and average tremor. (iii) The capsulorhexis modulerequires user to inject viscoelastic into the anterior chamberand then remove the capsular membrane using forceps.This simulates a very crucial step in cataract surgery, andtrainees have rated this as one of the most difficult steps incataract surgery to learn.20 The outcome measures for themodule were time to complete the task, average deviationfrom the circular path, injured cornea and lens area, as wellas stress on the incision.The study was standardized for all subjects. A single

investigator (T.D.B.L.) (unmasked to subjects’ level oftraining) supervised all simulator sessions; as well, theorder of tests conducted was standardized (in the orderdescribed earlier). Once informed consent had beenobtained and demographic information collected, subjectswere given a brief orientation to the simulator before thestudy session began. Performance scores were objectivelydetermined by the surgical simulator program on the basisof general outcome measures such as time required tocomplete the task, incision stress, corneal and lens injury,as well as criteria specific to each task (as described earlier).Each task was scored out of 100, and points were deductedor attributed according to the criteria set out by the simu-lator computer software.

Statistical analysis

All participants completed 3 trials for the forceps, anti-tremor, and capsulorhexis modules. Performance results,including mean scores and total time required to completethe task, as well as outcome measures specific to each task,were analyzed by subjects’ experience in ophthalmology,according to their level of training at the time of the study.Comparisons among the groups were carried out using anonparametric analysis of variance, the Kruskal–Wallistest, using SAS 9.2 statistics software, and Student’s t test,using Microsoft Excel 2007.

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RESULTS

There were a total of 65 subjects, and they were groupedaccording to their stated level of training (Table 1).Table 2 shows subjects’ performance results in the for-

ceps module (at difficulty level 2 out of 4), comparinggroups of different levels of training. Subjects in Group

A performed worse on all parameters compared with sub-jects in groups B, C, and D. Those with greater experiencehad significantly higher total scores than those who weremore inexperienced (p 5 0.011). Staff ophthalmologists(Group D) required the least amount of time to completethe task (77.8, SD 28.0 seconds), followed by senior oph-thalmology trainees (Group C, 84.0, SD 54.4 seconds),junior ophthalmology trainees (Group B, 97.6, SD 42.7seconds), and, the slowest, the medical students and OMTtrainees (Group A, 131.8, SD 57.9 seconds) (p 5 0.044).Table 3 shows the performance results for the antitre-

mor module (at difficulty level 3 out of 7). This analysisdemonstrates that those with greater levels of experienceperformed significantly better in the antitremor task thanthose with less experience. Groups C and D were signifi-cantly more time-efficient than groups A and B (p 5 0.005).Greater level of training was also positively correlatedwith greater accuracy and precision in the antitremor task(p 5 0.003), as shown by significantly lower out-of-tolerance percentages (a measure of the likelihood to devi-ate from the given circular path).Table 4 shows the performance results for the capsulor-

hexismodule (at difficulty level 4 out of 10). There were nosignificant differences in total scores and task parametersamong the groups.Five participants in the study had had prior exposure/

training on the Eyesi simulator. Their mean total scores onthe 3 tasks were compared with those at a similar stage oftraining (Table 5). The postgraduate year 2 (PGY-2) resi-dents with prior exposure to the Eyesi simulator achievedstatistically higher mean total scores on all 3 modules than

Table 1—Characteristics of participants as reported on studyquestionnaire (n 5 65)

Characteristic Group A Group B Group C Group D

Number 8 23 16 18

Sex, n (%)

Female 4 (50) 8 (35) 2 (13) 2 (11)

Male 4 (50) 15 (65) 14 (87) 16 (89)

Age, y

Mean 22.2 28.0 32.7 43.7

Range 21–24 25–31 28–42 33–61

Cataract surgeries performed

Mean 0 0.8 188.6 3147.1

Range – 0–15 0–500 100–10 000

Vitreoretinal surgeries performed

Mean 0 0.2 16.3 111.2

Range – 0–5 0–100 0–1000

Level of training

Medical Students 4 – – –

OMT trainees 4 – – –

PGY-1 – 5 – –

PGY-2 – 10 – –

PGY-3 – 8 – –

PGY-4 – – 8 –

PGY-5 – – 5 –

Fellows – – 3 –

Staff – – – 18

Mean years in practice (range) – – – 11.9 (2–26)

Note: Group A, medical students and ophthalmic medical technologist trainees; Group B,ophthalmology trainees in postgraduate years 1, 2, and 3; GroupC, ophthalmology traineesin postgraduate years 4 and 5, and fellows; Group D, staff ophthalmologists. (OMT,ophthalmic medical technologist; PGY, postgraduate year.)

Table 2—Performance on anterior segment forceps module (difficulty level 2 out of 4) according to stated level of training

Parameter

Mean (SD)

p valueGroup A (n 5 8) Group B (n523) Group C (n516) Group D (n518)

Total score, points 27.8 (29.4) 52.9 (29.4) 67.6 (21.1) 67.9 (18.4) 0.0106*

Total task time, seconds 131.8 (57.9) 97.6 (42.7) 84.0 (54.4) 77.8 (28.0) 0.0440*

Time, points lost 25.2 (3.2) 23.5 (2.6) 21.7 (1.1) 22.1 (1.6) 0.0102*

Incision stress value 7.9 (7.7) 6.4 (6.3) 1.9 (2.6) 4.5 (7.2) 0.0070*

Incision stress, points lost 213.2 (5.1) 211.6 (7.5) 25.6 (6.2) 27.7 (7.7) 0.0219*

Injured cornea (mm2) 0.4 (0.3) 0.2 (0.5) 0.1 (0.1) 0.0 (0.0) 0.0007*

Injured cornea, points lost 22.0 (1.5) 20.9 (2.6) 20.3 (0.7) 0.0 (0.0) 0.0002*

Injured lens area (%) 17.9 (10.6) 9.9 (8.0) 7.2 (4.6) 6.8 (5.6) 0.0255*

Injured lens area, points lost 235.9 (21.2) 220.5 (16.0) 214.4 (9.1) 213.6 (11.3) 0.0251*

*Statistically significant using Kruskal–Wallis analysis (p , 0.05)Note: Group A, medical students and ophthalmic medical technologist trainees; Group B, ophthalmology trainees in postgraduate years 1, 2, and 3; Group C, ophthalmology trainees inpostgraduate years 4 and 5, and fellows; Group D, staff ophthalmologists.

Table 3—Performance on anterior segment antitremor module (difficulty level 3 out of 7) according to stated level of training

Parameter

Mean (SD)

p valueGroup A (n58) Group B (n523) Group C (n516) Group D (n518)

Total score 8.5 (9.2) 41.2 (29.4) 45.8 ( 25.1) 46.7 (21.6) 0.0039*

Total task time, seconds 90.9 (18.8) 66.0 (22.4) 57.4 (14.7) 58.3 (18.5) 0.0052*

Time, points lost 22.8 (0.7) 22.0 (0.8) 21.6 (0.6) 21.7 (0.7) 0.0051*

Incision stress value 8.8 (9.1) 4.8 (4.8) 3.0 (3.2) 3.8 (5.4) 0.1194

Incision stress, points lost 212.1 (6.1) 211.2 (6.8) 27.9 (6.5) 27.2 (7.8) 0.1561

Out-of-tolerance percentage value 49.3 (9.7) 27.4 (20.5) 22.7 (12.3) 21.9 (9.9) 0.0026*

Average tremor (value) 34.9 (7.7) 38.2 (7.2) 36.7 (5.3) 37.2 (6.8) 0.8866

*Statistically significant using the Kruskal–Wallis analysis (p , 0.05)Note: Group A, medical students and ophthalmic medical technologist trainees; Group B, ophthalmology trainees in postgraduate years 1, 2, and 3; Group C, ophthalmology trainees inpostgraduate years 4 and 5, and fellows; Group D, staff ophthalmologists.

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58 CAN J OPHTHALMOL—VOL. 46, NO. 1, FEBRUARY 2011

other PGY-2 residents who had no prior exposure to theEyesi (p 5 0.01–0.03). For the PGY-4 residents there wereno statistically significant differences in mean total scoresachieved on the 3 modules between those with prior expo-sure to the simulator and those without (p 5 0.53–0.92).

DISCUSSION

Subjects’ level of training is predictive of their perform-ance on the forceps module according to the various scoringparameters. Staff ophthalmologists were 8% more efficient(total task time) than senior residents and fellows, 25%more efficient than junior residents, and 69% more effi-cient than medical students and OMT trainees (p 5 0.044).Overall, staff members made fewer errors and caused min-imal injury to the cornea, whereas senior residents andfellows injured 0.1 mm2 of the cornea. Junior residentshad twice the amount of injury to the cornea, and medicalstudents and OMT trainees had 4 times the amount ofinjury to the cornea in comparison to senior residentsand fellows (p 5 0.001). Staff had 6% fewer injuries tothe lens area than senior residents and fellows, 46% fewerthan junior residents, and 163% fewer than medical stu-dents and OMT trainees (p 5 0.026).Although we used a low level of difficulty (2 out of 4),

the forceps module was able to demonstrate constructvalidity in its ability to discriminate among subjects ofdifferent levels of training.The antitremor module also showed that experience is a

predictor of better outcomes in the various scoring para-meters. Staff ophthalmologists had the highest total score,

followed by senior residents and fellows, then junior resi-dents, and medical students and OMT trainees with thelowest score (p 5 0.004). Senior residents, fellows, andstaff were significantly more efficient than junior residentsby 13%–15% and than medical students and OMT trai-nees by 58%–56% (p 5 0.005). Staff had the greatestaccuracy in this task, showing the lowest out-of-tolerancepercentage value (a measure of deviation from the pre-scribed path), which was 4% more accurate than seniorresidents and fellows, 25% more accurate than junior resi-dents, and 125% more accurate than medical students andOMT trainees.Although the performance differences in the capsulorhexis

module did not reach significant levels, there was a gradientpattern whereby staff had the highest total score, followed bysenior residents and fellows, then junior residents, and finallymedical students andOMT trainees (p5 0.065). The lack ofsignificant differences among groups with different levels oftraining may have been partly due to the complexity of thecapsulorhexis module. The performance scores may be influ-enced by individuals’ susceptibility to learning and adaptingto novel technology. Studies have demonstrated that pre-vious video game experience significantly (p, 0.05) shortenstime to achieve proficiency in the Minimally Invasive Sur-gical Trainer-Virtual Reality simulator.21,22

Nevertheless, to our knowledge this is the largest studythat demonstrates the construct validity of the anteriorsegment forceps and antitremor modules. Consistent withprevious studies, the high-fidelity, virtual reality simulatorfor ophthalmic surgery shows that it could be a usefulassessment and training tool.1,3,17

Table 5—Comparison of total scores according to prior simulator experience

PGY-2 PGY-2 p value PGY-4 PGY-4 p value

Prior Eyesi experience Yes No Yes No

Number of subjects 3 7 2 6

Mean no. of prior cataract surgeries performed 0.7 (SD 1) 0 2.5 81

Cataract forceps total score 81.1 36.3 0.03* 73.8 59.1 0.53

Antitremor total score 76.8 33.8 0.03* 59.0 41.9 0.54

Capsulorhexis total score 12.9 8.1 0.01* 40.8 38.6 0.92

*Statistically significant using Student’s t test (p , 0.05).Note: PGY, postgraduate year.

Table 4—Performance on capsulorhexis module (difficulty level 4 out of 10) according to stated level of training

Parameter

Mean (SD)

p valueGroup A (n58) Group B (n523) Group C (n516) Group D (n518)

Total score 11.3 (19.6) 23.5 (19.6) 32.8 (23.7) 33.9 (24.5) 0.0654

Total task time, sec 178.4 (105.6) 138.5 (38.4) 139.8 (36.7) 130.3 (38.7) 0.7672

Time, points lost 21.6 (2.5) 21.4 (1.4) 21.2 (1.2) 21.0 (1.3) 0.7623

Incision stress value 0.4 (0.8) 1.6 (4.2) 0.6 (1.0) 0.4 (0.8) 0.7292

Incision stress, points lost 20.4 (1.1) 23.1 (5.2) 21.5 (2.7) 21.2 (3.1) 0.1799

Average radius of capsulorhexis value (mm) 1.7 (1.2) 2.5 (0.4) 2.5 (0.2) 2.4 (0.2) 0.2437

Decentration of capsulorhexis (mm) 0.5 (0.6) 0.4 (0.2) 0.4 (0.1) 0.4 (0.2) 0.9293

Decentration of capsulorhexis, points lost 237.3 (39.4) 229.0 (15.0) 228.9 (14.4) 236.0 (16.5) 0.3585

Overall irregularity of capsulorhexis value 0.3 (0.3) 0.2 (0.1) 0.2 (0.1) 0.2 (0.1) 0.6437

Overall irregularity of capsulorhexis, points lost 237.4 (39.9) 229.1 (22.8) 218.3 (14.0) 219.3 (17.0) 0.4913

Injured lens area (%) 13.2 (13.2) 12.0 (4.5) 12.0 (6.3) 12.6 (3.7) 0.8276

Injured cornea value (mm) 21.5 (3.2) 20.3 (1.0) 0.0 (0.1) 0.0 (0.1) 0.17655

Note: Group A, medical students and ophthalmic medical technologist trainees; Group B, ophthalmology trainees in postgraduate years 1, 2, and 3; Group C, ophthalmology trainees inpostgraduate years 4 and 5, and fellows; Group D, staff ophthalmologists.

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Intuitively, and as suggested byMahr andHodge,1 prac-tice on the simulator will likely lead to improved perform-ance on the study modules. Our study showed that juniorresidents who had had previous practice on the simulatoroutperformed their colleagues with no prior simulatorexposure on the forceps, antitremor, and capsulorhexismodules (p 5 0.01–0.03, Student’s t test). The differencesin total scores between senior residents with and withoutprior practice were not significant, perhaps because thegroup without prior simulator exposure had more real-lifecataract surgery experience (p 5 0.53–0.92). Gallagheret al.23 have suggested that simulation-based skill trainingallows for the automation of the necessary basic technicalskills and allows the trainee to place more focus on learningthe steps of an operation and handling unexpected events.Currently, a number of Canadian and American oph-

thalmology training programs have access to the Eyesi sys-tem. Further assessments of the surgical simulator shouldinvestigate whether skills learned on the simulator can betransferred to the operating room. As the acquisition ofsuch high-fidelity simulators can be costly, further researchwill help residency programs in their decision about adopt-ing this new technology.

Acknowledgments: The authors thank all the residents and staff inthe Department of Ophthalmology at the University of Toronto,University of Ottawa Eye Institute, and London Ivey Eye Institute,in particular Drs. Michael O’Connor (University of Ottawa), AlainProulx (University of Western Ontario), Marissa Sit (University ofToronto), and Rishi Gupta (University of Ottawa). We also thankthe organizers of the Canadian Ophthalmological Society 2007Meeting and Exhibition, as well as those of its members who volun-teered their time to participate in the study. Dr. Rahim Moineddin(University of Toronto) is acknowledged for his assistance with stat-istical analysis.

Disclosure: The authors have no proprietary or commercial interestin any materials discussed in this article.

Support: Toronto Western Hospital/University Health NetworkAcademic Enrichment Fund.

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