Dear Editor,

Virtual eye surgery (VES) simulators offer a safe and controlled environment to actively learn intraocular surgery. This includes gaining experience in the eye-hand-foot coordination required for intraocular surgery, the use of common microsurgical instruments, and the critical steps of key procedures such as capsulorhexis for cataract surgery and membrane peeling for vitreoretinal surgery [1–3]. However, the role of VES simulators in the education of ophthalmologists-in-training is unclear: they appear to improve surgical skills as measured by the simulator and wet-lab performance but there is a paucity of data showing improved operating room performance [1, 4]. To learn more about the current status of VES in ophthalmic graduate medical education, we surveyed United States (US) ophthalmology residency program directors on the role of VES simulators in their programs.

After being granted an exemption from the Providence Veterans Affairs Medical Center Institutional Review Board, an anonymous survey consisting of multiple choice and Likert-style questions (Tables 1, 2) was created on www.surveymonkey.com. The survey link was sent to the 117 Accreditation Council for Graduate Medical Education Ophthalmology Residency Program Directors listed on the FREIDA online database (www.ama-assn.org/go/freida). Each survey question was analyzed independently with the denominator being the total number of responses to the question.

Table 1 Utilization of virtual eye surgery simulators in residency programs
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Table 2 Program director insights regarding virtual eye surgery simulators
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The results of the survey are summarized in Tables 1 and 2. The response rate was 47.9% (56/117). A VES simulator was used by 23% (13/56) of residency training programs. Among the programs without a VES simulator, cost was the main limiting factor (98%, 41/42) followed by inadequate simulator realism (26%, 11/42), and the unproven validity of VES (21%, 9/42). Among programs using VES simulators, (100%; 10/10) used the EyeSi simulator (VRmagic, Mannheim, Germany); (69%, 9/13) mandated its use in the educational curriculum and (50%, 6/12) used it to evaluate resident surgical skills quantitatively. A VES simulator had been personally used by 75% (38/51) of program directors; 21% (9/42) of program directors reported that department faculty used a VES simulator to help residents improve surgical skills. Most program directors agreed that VES is a useful tool for improving and measuring resident surgical skills and that it could be incorporated into the resident training model; however, they did not support VES evolving into a mandatory component of resident training.

This study has several limitations. The survey response rate of 47.9% may limit the generalizability of the results, though it exceeds the 32% response rate of a recent US program director survey [5] and the 34% mean response rate for e-mail surveys reported in a recent meta-analysis [6]. In addition, the survey may have been biased by the multiple choice rather than open-ended nature of the questions and by the large number of responses from residency programs without VES simulators.

This study suggests that while many US program directors have previous experience with a VES simulator and view it as a useful educational tool, VES simulators are currently used in only a minority of US ophthalmology residency programs due primarily to their high cost. Further research is needed on the role of VES in ophthalmic graduate medical education, especially in demonstrating improved virtual reality-to-operating room outcomes compared to more traditional methods of surgical education [1, 2, 4, 7].