Update on Simulation-Based Surgical Training and Assessment in Ophthalmology A Systematic Review Ann Sofia S. Thomsen, MD, 1,2 Yousif Subhi, BScMed, 2 Jens Folke Kiilgaard, MD, PhD, 1 Morten la Cour, DMSc, MD, 1 Lars Konge, PhD, MD 2 Topic: This study reviews the evidence behind simulation-based surgical training of ophthalmologists to determine (1) the validity of the reported models and (2) the ability to transfer skills to the operating room. Clinical Relevance: Simulation-based training is established widely within ophthalmology, although it often lacks a scientific basis for implementation. Methods: We conducted a systematic review of trials involving simulation-based training or assessment of ophthalmic surgical skills among health professionals. The search included 5 databases (PubMed, EMBASE, PsycINFO, Cochrane Library, and Web of Science) and was completed on March 1, 2014. Overall, the included trials were divided into animal, cadaver, inanimate, and virtual-reality models. Risk of bias was assessed using the Cochrane Collaboration’s tool. Validity evidence was evaluated using a modern validity framework (Messick’s). Results: We screened 1368 reports for eligibility and included 118 trials. The most common surgery simu- lated was cataract surgery. Most validity trials investigated only 1 or 2 of 5 sources of validity (87%). Only 2 trials (48 participants) investigated transfer of skills to the operating room; 4 trials (65 participants) evaluated the effect of simulation-based training on patient-related outcomes. Because of heterogeneity of the studies, it was not possible to conduct a quantitative analysis. Conclusions: The methodologic rigor of trials investigating simulation-based surgical training in ophthal- mology is inadequate. To ensure effective implementation of training models, evidence-based knowledge of validity and efficacy is needed. We provide a useful tool for implementation and evaluation of research in simulation-based training. Ophthalmology 2015;122:1111-1130 ª 2015 by the American Academy of Ophthal- mology. Misconceptions of key aspects in surgical training and assessment can lead to suboptimal research and training programs within the area. An evidence-based approach to new training models is paramount to deliver satisfactory patient outcomes, and we are far behind in developing such an approach. Although simulation has a long history in training pro- grams in various domains, such as the aviation industry, the use of simulation in surgical training is more recent. “See one, do one, teach one” has been the dominating paradigm in surgical education for decades, but legal and ethical concerns about using patients for training purposes have led to increasing interest in simulation-based training, including in ophthalmology. The apprenticeship model using patients as teaching cases is associated with increased complication rates 1e12 and worse patient outcomes. 13,14 Furthermore, training surgical residents in the operating room increases costs because of increased operating times. 15e17 Generally, concerns have been raised regarding the number of residents who struggle with surgical competency, 18 and several studies have reported significant perceived deficiencies in surgical training of residents. 19e21 Therefore, alternative training models are needed, and simulation models may be the answer because they offer standardized, controlled training scenarios without endangering patients. Besides the need for alternative training models, there is also a need for objective assessment tools with which to evaluate surgical competency in ophthalmology. 22 Programs typically require residents to complete a minimum number of procedures before graduating (Accreditation Council for Graduate Medical Education and Royal College of Ophthalmology), although performing a required number of surgeries does not ensure competency. However, the use of simulation models can ensure a basic level of competency. 23 Different categories of simulation models are used for assessment and training purposes, including animal, cadaver, inanimate, and virtual-reality models. The Accreditation Council for Graduate Medical Education mandates access to a surgical simulation model (wet lab or virtual-reality simulator [VRS]), 24 and several curricula emphasize the use of simulation-based training and 1111 Ó 2015 by the American Academy of Ophthalmology Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ophtha.2015.02.028 ISSN 0161-6420/15