Development of a virtual reality training curriculum for phacoemulsification surgery

Authors: Spiteri, Aggarwal, Kersey, Sira, Benjamin, Darzi, Bloom.

Publication: Eye (Lond). 2014 Jan; 28(1):78-84. doi: 10.1038/eye.2013.211.



Training within a proficiency-based virtual reality (VR) curriculum may reduce errors during real surgical procedures. This study used a scientific methodology to develop a VR training curriculum for phacoemulsification surgery (PS).

Patients and methods

Ten novice-(n) (performed <10 cataract operations), 10 intermediate-(i) (50–200), and 10 experienced-(e) (>500) surgeons were recruited. Construct validity was defined as the ability to differentiate between the three levels of experience, based on the simulator-derived metrics for two abstract modules (four tasks) and three procedural modules (five tasks) on a high-fidelity VR simulator. Proficiency measures were based on the performance of experienced surgeons.


Abstract modules demonstrated a ‘ceiling effect’ with construct validity established between groups (n) and (i) but not between groups (i) and (e)—Forceps 1 (46, 87, and 95; P<0.001). Increasing difficulty of task showed significantly reduced performance in (n) but minimal difference for (i) and (e)—Anti-tremor 4 (0, 51, and 59; P<0.001), Forceps 4 (11, 73, and 94; P<0.001). Procedural modules were found to be construct valid between groups (n) and (i) and between groups (i) and (e)—Lens-cracking (0, 22, and 51; P<0.05) and Phaco-quadrants (16, 53, and 87; P<0.05). This was also the case with Capsulorhexis (0, 19, and 63; P<0.05) with the performance decreasing in the (n) and (i) group but improving in the (e) group (0, 55, and 73; P<0.05) and (0, 48, and 76; P<0.05) as task difficulty increased.


Experienced/intermediate benchmark skill levels are defined allowing the development of a proficiency-based VR training curriculum for PS for novices using a structured scientific methodology.