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The introduction and development of VR simulators has been one of the main innovations that have resulted in a change in training curricula in surgery. Satava was the first to recommend VR simulation as a complement to current training models .
The role of simulation in surgery is to provide our trainees with the opportunity to learn basic tasks in a safe and controlled environment. All movements the trainee makes can be recorded and therefore there is the facility for immediate and objective feedback. It is also possible to set a proficiency level on a simulator and therefore design a training program giving set goals that a trainee needs to accomplish before being allowed perform in the operating theatre. All of these factors contribute to skill learning, assessment, selection and credentialing. Simulators will also be invaluable in the teaching of the newer forms of surgery, single incision laparoscopy and natural orifice transluminal endoscopic surgery. The use of simulation should provide the setting in which challenges such as the use of new instruments and technology can be overcome. An example of this is in single incision laparoscopic surgery where it is difficult to have instruments working parallel to each other in a very narrow operative field.
Although the benefits of performance feedback are not debated, questions remain about the optimal way to provide this. Research is currently been conducted to analyse the optimal frequency and type of feedback. It has been shown that feedback delivered in a standardised and structured manner results in an improvement in simulator performance . It has also been found that providing feedback has resulted in a shortening of the minimally invasive surgery learning curve .
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We identified 12,490 unique records in our literature search; 87 met final eligibility criteria, comprising studies that evaluated the use of extended reality in education (n=54), diagnostics (n=5), and therapeutics (n=28). Of these, 79 studies (91%) achieved evidence levels in the range 2b to 4, indicating poor quality. Only 2 (9%) out of 22 relevant studies addressed all 5 sources of validity evidence. In education, we found that ophthalmic surgical simulators demonstrated efficacy and validity in improving surgical performance and reducing complication rates. Ophthalmoscopy simulators demonstrated efficacy and validity evidence in improving ophthalmoscopy skills in the clinical setting. In diagnostics, studies demonstrated proof-of-concept in presenting ocular imaging data on extended reality platforms and validity in assessing the function of patients with ophthalmic diseases. In therapeutics, heads-up surgical systems had similar complication rates, procedural success rates, and outcomes in comparison with conventional ophthalmic surgery.
In medicine, the nascent influence of extended reality is prevalent. Virtual reality platforms have been designed to teach foundational subjects, such as human anatomy [6,7], and train surgeons in complex surgical procedures [8-11]. Augmented and mixed reality offer methods of visualizing intraoperative procedures and diagnostic images with devices, such as Google Glass (Google Inc) or Microsoft HoloLens (Microsoft Inc), that have the potential to improve procedure safety and success [12-14]. The ability of virtual reality to distract patients from the physical environment also offers therapeutic approaches for rehabilitation and for treating pain or psychiatric disorders [15-17]. Likewise, ophthalmology has seen a growing influence of extended reality. Ophthalmic graduate medical education in the United States has seen an increase in the use of virtual eye surgery simulators, from 23% in 2010 to 73% in 2018 [18,19]. Extended reality technologies have also been explored as a method of therapy in ophthalmic diseases such as amblyopia and visual field defects [20,21]. Although the versatility of extended reality platforms can influence the practice of ophthalmology, health care providers should be well informed of the benefits and limitations of such technologies. This will allow evidence-based decision making when adopting nascent methods of ophthalmic education, diagnosis, and treatment. The focus of this review was to systematically evaluate current evidence of the efficacy, validity, and utility of the application of extended reality in ophthalmic education, diagnostics, and therapeutics.
Of 46 studies evaluating surgical simulators, the EyeSi surgical simulator (VR Magic) was most commonly used (n=38). Others included MicroVisTouch (ImmersiveTouch) (n=1), PixEye Ophthalmic Simulator (SimEdge SA) (n=1), and 6 self-designed simulators. The most common surgical procedure simulated in these studies was cataract surgery (n=36), followed by vitreoretinal procedures (n=9), laser trabeculoplasty (n=1), and corneal laceration repair (n=1).
For the EyeSi surgical simulator, most studies found that the surgical performance of experienced participants was significantly better than that of less-experienced participants. Sikder et al  found that intervening surgical experience significantly improved capsulorhexis performance on the MicroVisTouch cataract surgery simulator. Lam et al  showed that in a self-made phacoemulsification simulator, more experienced participants attained significantly higher scores in all main procedures and completed tasks significantly faster.
Although a wide range of clinically evaluated ophthalmic applications of extended reality were identified, we predominantly focused on the following domains: education, diagnostics, and therapeutics. In education, simulators demonstrated efficacy and validity in improving surgical and ophthalmoscopy skills. In diagnostics, extended reality devices demonstrated proof-of-concept in displaying ocular imaging data and validity in assessing the function of patients with glaucoma. In therapeutics, heads-up surgical systems were found to be efficacious and safe alternatives to conventional microscope surgery. The overall evidence, however, for the utility of these applications is limited. Only 8 of 87 (9%) studies had OCEBM levels of evidence of 1b, which represented randomized trials with a narrow confidence interval, while 79 of 87 (91%) studies had OCEBM levels of evidence ranging from 2b to 4 (cohort studies, case-control studies, and case series). For extended reality applications only evaluated by 1 or 2 studies, this limited evidence makes it difficult to extrapolate their utility in a wider context. 2b1af7f3a8