Purpose 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 o10 cataract operations), 10 intermediate-(i) (50-200), and 10 experienced-(e) (4500) 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. Results 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; Po0.001). Increasing difficulty of task showed significantly reduced performance in (n) but minimal difference for (i) and (e)-Anti-tremor 4 (0, 51, and 59; Po0.001), Forceps 4 (11, 73, and 94; Po0.001). Procedural modules were found to be construct valid between groups (n) and (i) and between groups (i) and (e)-Lenscracking (0, 22, and 51; Po0.05) and Phacoquadrants (16, 53, and 87; Po0.05). This was also the case with Capsulorhexis (0, 19, and 63; Po0.05) with the performance decreasing in the (n) and (i) group but improving in the (e) group (0, 55, and 73; Po0.05) and (0, 48, and 76; Po0.05) as task difficulty increased. Conclusion 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.

BACKGROUND The quality of ophthalmic surgical training is increasingly challenged by an untimely convergence of several factors. This article reviews the tools currently available for training and assessment in phacoemulsification surgery. METHODS Medline searches were performed to identify articles with combinations of the following words: phacoemulsification, training, curriculum, virtual reality and assessment. Further articles were obtained by manually searching the reference lists of identified papers. RESULTS Thus far phacoemulsification training outside the operating room include wet labs and micro-surgical skills courses. These methods have been criticised for being unrealistic, inaccurate and inconsistent. Virtual reality simulators have the ability to teach phacoemulsification psychomotor skills, as well as to carry out objective assessment. Other ophthalmic surgical skill assessment tools such as Objective Assessment of Skills in Intraocular Surgery (OASIS) and Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) are emerging. Assessor bias is minimised by using video-based assessments, which have been shown to reduce subjectivity. Dexterity analysis technology such as the Imperial College Surgical Assessment Device (ICSAD) and virtual reality simulators can be used as objective assessment devices. CONCLUSION Improvements in technology can be utilised in ophthalmology and will help to address the increasingly limited opportunities for training and assessment during training and throughout a subsequent career (re-training and re-validation). This will inevitably translate into enhanced patient care.

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The authors present a case of secondary glaucoma associated with silicone oil in a patient with ocular cicatricial pemphigoid successfully managed with transscleral diode laser cyclophotocoagulation. Six months following treatment, the patient remained satisfied and free of pain, with an intraocular pressure of 24 mm Hg without topical drops or oral acetazolamide. There was no evidence of exacerbation of ocular cicatricial pemphigoid and no adjustment was required to the patient's immunosuppressive therapy. This case suggests that transscleral diode laser cyclophotocoagulation may be safely used to control raised intraocular pressure in patients with ocular cicatricial pemphigoid without causing an exacerbation of the condition.