Effect of Virtual Reality Simulation Training on Real-Life Cataract Surgery Complications: Systematic Literature Review

Author: Rothschild P, Richardson A, Beltz J, Chakrabarti R.

Geographical coverage: Not reported

Sector: Impact/Economic Evaluation

Sub–sector: Impact/Costs

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background: Cataract surgery is the most frequently performed operation worldwide and has traditionally been taught through an apprenticeship model. However, heightened attention to patient safety, reduced trainee working hours and efficiency demands have shifted the dynamics of surgical education towards simulation‑based learning. Virtual reality simulation (VRS), particularly the EyeSi platform, offers a high‑fidelity environment for deliberate and structured practice of complex surgical steps. Over the past two decades, VRS has gained popularity within ophthalmology training programmes. Capsulorhexis – a critical and challenging step in cataract surgery – has shown construct validity when taught on VRS. Despite its growing uptake, questions remain about how effectively VRS translates into improved real‑life surgical outcomes. Proper integration into training curricula and structured evaluation are therefore essential to maximise its potential.

Objective: To determine whether VRS training reduces the complication rate in subsequent real‑life cataract surgery.

Main findings: Ten studies published between 2011 and 2020 were included. Together they involved 471 ophthalmology trainees who performed 30,462 cataract operations, after which complication rates were assessed. None of the studies was retrospective, and risk‑of‑bias assessments were broadly similar across categories (classified as high, low or unclear). The evidence suggested that VRS was most effective in lowering posterior capsular rupture (PCR) rates, with several studies reporting statistically significant improvements. For example, the Royal College of Ophthalmologists’ National Ophthalmology Database Audit recorded a meaningful decline in PCR following implementation of VRS. Conversely, evidence for reductions in other complications – such as vitreous loss or retained lens material – was limited.

Methodology:  Searches of PubMed/MEDLINE, Web of Science, the Cochrane Library and CINAHL from 1 January 1990 to 8 January 2020 identified English‑language studies evaluating the impact of VRS (e.g. EyeSi) on real‑life cataract surgery outcomes. Reference lists of included papers were screened for additional publications. Two reviewers independently screened titles and abstracts, resolved disagreements through discussion, extracted data using a piloted chart and assessed risk of bias with the Cochrane Collaboration criteria. Owing to heterogeneity, the findings were synthesised narratively.

Applicability/external validity: Most studies examined structured programmes in high‑resource institutions, leaving gaps in the evidence for shorter or informal training pathways. Cost‑effectiveness has been demonstrated in the United Kingdom, yet access barriers may restrict global uptake. Multicentre studies are needed to validate broader use and to explore effects beyond technical proficiency, such as decision‑making in real‑world surgical settings.

Geographic focus: No geographical limits were applied, although the review did not report the distribution of included studies.

Summary of quality assessment: Overall confidence in the conclusions is low. Search strategies were comprehensive and inclusion/exclusion criteria clearly defined. Two reviewers independently screened, extracted data and assessed bias using established tools. Study characteristics were documented and heterogeneity was discussed. However, the review did not supply a list of excluded studies and findings were not stratified by risk‑of‑bias status.