The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Teleophthalmology in the United States Army: A Review From 2004 Through 2018.

INTRODUCTION: We describe results of the U.S. Army Ocular Teleconsultation program from 2004 through 2018 as well as the current condition, benefits, barriers, and future opportunities for teleophthalmology in the clinical settings and disease areas specific to the U.S. Military. MATERIALS AND METHODS: This was a retrospective, noncomparative, consecutive case series. A total of 653 ocular teleconsultations were reviewed; 76 concerned general policy questions and underwent initial screening to determine the year each request was received, the average and median initial consultant response time, the number of participating consultants, the country from which the request originated, the military status and branch of each U.S. patient for which a request was submitted, and the nationality, age, and military status of foreign patients for whom consults were requested. The remaining 577 requests were further analyzed to determine the diagnostic category of the request, whether or not an evacuation recommendation was provided by a consultant, the relationship of the request to trauma, if and what type of nonocular specialty consultant(s) participated in the consultation request, and if and what type of ancillary imaging accompanied the request. RESULTS: The number of requests was 13 in 2004, compared to 80 in 2011 and 11 in 2018. The average response time in 2018 was 2.27 hours compared to 9. 73 hours in 2004. The number of participating ocular specialists was 5 in 2004, compared to 39 in 2013 and 13 in 2018. Requests originating from Iraq and Afghanistan comprised 61.1% (399/653) of requests. The U.S. Army personnel comprised the largest percentage of consults at 38.6% (252/653). Nonmilitary patients from the USA accounted for 18.5% (121/653) of consults. Non-U.S. patients including coalition forces, contractors, detainees, and noncombatants accounted for 14.4% (94/653) of consults, of which 22% (21/94) were children. Anterior segment consults accounted for 45.1% (260/577) of consults, with corneal surface disease being the largest subset within this diagnostic category. Evacuation was recommended in 22.7% (131/577) of overall cases and 41.1% (39/95) of trauma cases. Requests were associated with either combat-related or accidental trauma in 16.5% (95/577) of cases. Dermatology and neurology were the most commonly co-consulted specialties, representing 40.0% (32/80) and 33.75% (27/80) of consults, respectively. Photographs of suspected ocular pathology accompanied 37.4% of consults, with the likelihood requesters included photographs being greatest in cases involving pediatric ophthalmology (7/9, 77.8%) and oculoplastics (86/120, 71.7%). CONCLUSIONS: Army teleophthalmology has been an indispensable resource in supporting and advancing military medicine, helping to optimize the quality, efficiency, and accessibility of ophthalmic care for U.S. Military personnel, beneficiaries, allied forces, and local nationals worldwide. A dedicated ophthalmic care and coordination system which utilizes new advances in teleconsultation technology could further enhance our current capability to care for the ophthalmic needs of patients abroad, with opportunity for improving domestic care as well.

A Sub-Analysis of U.S. Africa Command Area of Operations Transportations for Ophthalmic Concerns, 2008-2018.

INTRODUCTION: American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018. METHODS: We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions. RESULTS: Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary. CONCLUSION: Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

Traumatic brain injury and sight loss in military and veteran populations- a review.

War and combat exposure pose great risks to the vision system. More recently, vision related deficiencies and impairments have become common with the increased use of powerful explosive devices and the subsequent rise in incidence of traumatic brain injury (TBI). Studies have looked at the effects of injury severity, aetiology of injury and the stage at which visual problems become apparent. There was little discrepancy found between the frequencies or types of visual dysfunctions across blast and non-blast related groups, however complete sight loss appeared to occur only in those who had a blast-related injury. Generally, the more severe the injury, the greater the likelihood of specific visual disturbances occurring, and a study found total sight loss to only occur in cases with greater severity. Diagnosis of mild TBI (mTBI) is challenging. Being able to identify a potential TBI via visual symptoms may offer a new avenue for diagnosis.

The ABCs of Ocular Trauma: Adapting a Familiar Mnemonic for Rapid Eye Exam in the Pre-Ophthalmic Zone of Care.

Evaluation and management of eye trauma is daunting to many practitioners. For general medical emergencies, the familiar ABCs mnemonic serves to both recompose the provider as well as provide a logical order for evaluation and action. We recently adapted an ABCs mnemonic to provide non-ophthalmologists with a familiar method for systematically evaluating and managing eye trauma. A = ACUITY. Visual acuity is the most importance piece of information in eye trauma. B = BEST exam of BOTH eyes. Starting with acuity, examination proceeds from the front to the rear of the eye. Examine the uninjured eye first. C = CONTIGUOUS STRUCTURES and CONTACT LENSES. Examine structures contiguous to the apparent injury. Inspect for contact lens wear. D = DRUGS, DIAGNOSTIC IMAGING, and the DON'TS. Start antibiotics, antiemetics, and analgesics. Administer tetanus. Obtain computerized tomography if available. Do not attempt ocular ultrasound or magnetic resonance imaging. Do not apply pressure to the eye. Do not patch the eye or apply any medication. E = EYE SHIELD and EVACUATE. Shield and ship to ophthalmology. The mnemonic was adapted to reflect current Joint Trauma Services and Tactical Combat Casualty Care practice guidelines. We believe this familiar mnemonic will serve as a useful tool in allowing non-ophthalmologists to comfortably and safely evaluate an eye for trauma.

The Joint Pathology Center/Vision Center of Excellence Approach to Analyzing Intra-Ocular "Foreign Bodies".

BACKGROUND: The Military Health System recognizes the importance of analyzing "foreign bodies" removed from US service members through several policy documents. This activity focuses on detecting potentially toxic metals. Intra-ocular "foreign bodies" (IOFBs) represent a small, clinically important subset. The development of ocular metallosis with iron and copper fragments is a specific local reaction to IOFBs. The results of the compositional analysis of removed IOFBs can influence clinical management decisions aimed at optimizing the preservation of sight. METHOD: The Joint Pathology Center (JPC) and Vision Center of Excellence (VCE) have established a pathway for the analysis of IOFBs removed from Department of Defense and Veterans Health Administration patients. The analysis of IOFBs uses analytical methods to provide information about the fragments' surface elemental and molecular composition. RESULTS: Metallic specimens analyzed included iron and copper-containing fragments. Non-metallic IOFBs analyzed include glass, plastic (polyurethane), and nitro-cellulose fragments. CONCLUSION: The JPC/VCE approach to analyzing IOFBs promotes uniform handling and shipping of specimens to minimize contamination. The analytical approach allows for the characterization of IOFBs with a wide variety of compositions. The results support clinical management decisions aimed at optimal treatment for the preservation of patients' visual acuity.

Simplified Method for Rapid Field Assessment of Visual Acuity by First Responders After Ocular Injury.

Objective: Initial visual acuity after ocular injury is an important measure, as it is an accurate predictor of final visual outcome and gives a rapid estimation of the overall severity of the injury, thereby aiding evacuation prioritization. We devised a simple method for rapidly assessing visual acuity in the field without having to rely on formal screening cards. Methods: Using common objects, icons, and text found in the injury zone - for example, common military name tapes, rank insignias, patches, emblems, and helmet camouflage bands, which will be known collectively as the Army Combat Optotypes (ACOs) - a Snellen-equivalent method of assessing visual acuity was devised and correlated to the ocular trauma score (OTS). Results: Ability to read the ACOs at 2, 3, and 5 ft correlates with acuities in the range from 20/20 to 20/400. Identification of ACOs with visual acuity of 20/50 and 20/200 approximates important inflection points of severity for the OTS. Conclusion: Accurately assessing visual acuity in the field after ocular injury provides essential information but does not require sophisticated screening equipment. Pertinent and accurate acuities can be rapidly estimated using commonly available text or graphical icons such as standard name tapes, patches, and rank insignias.

Ocular Manifestations of Mosquito-Transmitted Diseases.

Of the 3,548 known mosquito species, about 100 transmit human diseases. Mosquitoes are distributed globally throughout tropical and temperate regions where standing water sources are available for egg laying and the maturation of larva. Female mosquitoes require blood meals for egg production. This is the main pathway for disease transmission. Mosquitoes carry several pathogenic organisms responsible for significant ocular pathology and vision loss including West Nile, Rift Valley, chikungunya, dengue viruses, various encephalitis viruses, malarial parasites, Francisella tularensis, microfilarial parasites, including Dirofilaria, Wuchereria, and Brugia spp., and human botfly larvae. Health care providers may not be familiar with many of these mosquito-transmitted diseases or their associated ocular findings delaying diagnosis, treatment, and recovery of visual function. This article aims to provide an overview of the ocular manifestations associated with mosquito-transmitted diseases.

Atropine Eye Drops: A Proposed Field Expedient Substitute in the Absence of Atropine Autoinjectors.

Nerve agents are a threat to military and civilian health. The antidote, atropine sulfate, is delivered by autoinjector, which is a limited resource. We propose the use of 1% atropine ophthalmic solution (supplied commercially in 5mL or 15 mL bottles) via oral, ocular, and intranasal administration as an expedient substitute in austere environments.

Self-Reported Visual Quality of Life After Combat Ocular Trauma.

OBJECTIVES: To describe the visual outlook and quality of life of service members after combat ocular trauma. METHODS: In a single-center, prospective observational study of service members sustaining ocular trauma, participants underwent a series of ocular examinations and noninvasive tests, including the National Eye Institute Visual Functioning Questionnaire (VFQ-25). RESULTS: Of the 165 enrolled participants, 137 completed the VFQ-25. The mean VFQ-25 composite score was 74.4 ± 20.7 (range: 1.4-100). Among 118 participants with visual acuity assessment, 92% had best corrected visual acuity (BCVA) of 20/20 or better in at least one eye. Among participants with severe vision loss (BCVA ≤20/200), there was no statistically significant difference in self-reported general health compared to those without severe vision loss (p = 0.17). However, there was a significantly lower visual quality of life reported in the composite score and all of the 11 subscales of the VFQ-25. CONCLUSIONS: While this study provides evidence that combat ocular trauma is associated with a lower visual quality of life, limitations include the relatively small sample size and the limited documentation of the use of eye protection at time of injury among participants.

The use of rigid eye shields (Fox shields) at the point of injury for ocular trauma in Afghanistan.

BACKGROUND: Unlike hemorrhagic injuries in which direct pressure is indicated, any pressure placed on the eye after penetrating trauma can significantly worsen the injury by expulsing intraocular contents. The accepted first response measure for obvious or suspected penetrating ocular injury is placement of a rigid shield that vaults the eye so as to prevent accidental iatrogenic aggravation during transport to the ophthalmologist. Patching and placing intervening gauze between the shield and the eye are both contraindicated. Anecdotally, compliance with these recommendations is poor in the military and civilian communities alike; however, published studies documenting compliance are uniformly lacking. This study was undertaken to provide such an evaluation. METHODS: In this retrospective observational study, the Department of Defense Trauma Registry was reviewed to identify eye injuries in Afghanistan from 2010 to 2012 and to examine compliance with eye shield recommendations. One hundred fifty-seven records of eye casualties were identified and categorized according to diagnostic codes, noting use of a shield. A subset of 30 records was further analyzed for compliance with other core treatment measures specified by the operant Clinical Practice Guideline. Because comparative studies do not exist, simple statistical analysis was performed. RESULTS: Overall, 39% of eye injuries received a shield at the point of injury (61% failure), ranging from 0% to 50% between diagnostic subgroups. Subset analysis revealed that only 4.2% of injuries were successfully mitigated at the point of injury (95.8% failure). CONCLUSION: In one of the few studies documenting the use of eye shields after ocular trauma, anecdotal reports of poor, inadequate, or incorrect compliance with basic recommendations were substantiated. Several factors may account for these findings. Corrective efforts should include enhanced educational emphasis and increased shield availability. LEVEL OF EVIDENCE: Epidemiologic study, level IV. Therapeutic study, level IV.

Ocular blast injuries in mass-casualty incidents: the marathon bombing in Boston, Massachusetts, and the fertilizer plant explosion in West, Texas.

PURPOSE: To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas. DESIGN: Multicenter, cross-sectional, retrospective, comparative case series. PARTICIPANTS: Seventy-two eyes of 36 patients treated at 12 institutions were included in the study. METHODS: Ocular and systemic trauma data were collected from medical records. MAIN OUTCOME MEASURES: Types and severity of ocular and systemic trauma and associations with mechanisms of injury. RESULTS: In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P<0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified. CONCLUSIONS: Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

Pediatric PRK (PhotoRefractive Keratectomy) with Mitomycin C (MCC) for Persistent Anisometropic Amblyopia. A Case Report.

PURPOSE: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) with Mitomycin C (MMC) for the treatment of severe pediatric anisometropia and amblyopia resistant to more conservative treatment modalities. METHODS: A 3 year-old-child, who at 18 months old underwent unilateral diode laser treatment for threshold ROP, developed 11 diopters of anisometropic myopia and secondary dense amblyopia of the Right Eye. Only after all conservative treatment options failed was he treated with PRK and MMC. Principal outcome measures included cycloplegic refraction, the amount of refractive correction, degree of corneal haze and change in visual acuity. RESULTS: On presentation: BCVA: 20/CF OD; 20/30 OS. CRNS: -11.50 diopters sphere OD; -0.50 diopters sphere OS. Unilateral PRK followed by application of MMC (0.2 mg/ml) for 1 min was performed under general anesthesia. Three-month postoperative findings include: VA: 20/30 OD; 20/25 OS. CRNS: +0.25 diopters sphere OD. At one year, the BCVA remained equal at the 20/30 level despite mild myopic regression OD. CRNS OD at one year was -1.25 +050 x 116. No corneal haze was appreciated. CONCLUSION: In this child, treatment with PRK and MMC safely reduced the anisometropia thus facilitating his visual rehabilitation. While encouraging, further study is required to verify the longer term results of this single case. PURPOSE: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) with Mitomycin C (MMC) for the treatment of severe pediatric anisometropia and amblyopia resistant to more conservative treatment modalities. METHODS: A 3 year-old-child, who at 18 months old underwent unilateral diode laser treatment for threshold ROP, developed 11 diopters of anisometropic myopia and secondary dense amblyopia of the Right Eye. Only after all conservative treatment options failed was he treated with PRK and MMC. Principal outcome measures included cycloplegic refraction, the amount of refractive correction, degree of corneal haze and change in visual acuity. RESULTS: On presentation: BCVA: 20/CF OD; 20/30 OS. CRNS: -11.50 diopters sphere OD; -0.50 diopters sphere OS. Unilateral PRK followed by application of MMC (0.2 mg/ml) for 1 min was performed under general anesthesia. Three-month postoperative findings include: VA: 20/30 OD; 20/25 OS. CRNS: +0.25 diopters sphere OD. At one year, the BCVA remained equal at the 20/30 level despite mild myopic regression OD. CRNS OD at one year was -1.25 +050 x 116. No corneal haze was appreciated. CONCLUSION: In this child, treatment with PRK and MMC safely reduced the anisometropia thus facilitating his visual rehabilitation. While encouraging, further study is required to verify the longer term results of this single case.

The United States Army Ocular Teleconsultation program 2004 through 2009.

PURPOSE: To describe the United States Army Ocular Teleconsultation program and all consultations received from its inception in July 2004 through December 2009. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: All 301 consecutive ocular teleconsultations received were reviewed. The main outcome measures were differential diagnosis, evacuation recommendations, and origination of consultation. Secondary measures included patient demographics, reason for consultation, and inclusion of clinical images. RESULTS: The average response time was 5 hours and 41 minutes. Most consultations originated from Iraq (58.8%) and Afghanistan (18.6%). Patient care-related requests accounted for 94.7% of consultations; nonphysicians submitted 26.3% of consultations. Most patients (220/285; 77.2%) were United States military personnel; the remainder included local nationals and coalition forces. Children accounted for 23 consultations (8.1%). Anterior segment disease represented the largest grouping of cases (129/285; 45.3%); oculoplastic problems represented nearly one quarter (68/285; 23.9%). Evacuation was recommended in 123 (43.2%) of 285 cases and in 21 (58.3%) of 36 cases associated with trauma. Photographs were included in 38.2%, and use was highest for pediatric and strabismus (83.3%) and oculoplastic (67.6%) consultations. Consultants facilitated evacuation in 87 (70.7%) of 123 consultations where evacuation was recommended and avoided unnecessary evacuations in 28 (17.3%) of 162 consultations. CONCLUSIONS: This teleconsultation program has brought valuable tertiary level support to deployed providers, thereby helping to facilitate appropriate and timely referrals, and in some cases avoiding unnecessary evacuation. Advances in remote diagnostic and imaging technology could further enhance consultant support to distant providers and their patients.

Virtual reality simulation in acquiring and differentiating basic ophthalmic microsurgical skills.

OBJECTIVE: A virtual reality (VR) surgical simulator (EyeSi ophthalmosurgical simulator: VRMagic, Mannheim, Germany) was evaluated as a part-task training platform for differentiating and developing basic ophthalmic microsurgical skills. METHODS: Surgical novice performance (residents, interns, and nonmicrosurgical ophthalmic staff) was compared with surgical expert performance (practicing ophthalmic microsurgeons) on a basic navigational microdexterity module provided with the EyeSi simulator. RESULTS: Expert surgeons showed a greater initial facility with all microsurgical tasks. With repeated practice, novice surgeons showed sequential improvement in all performance scores, approaching but not equaling expert performance. CONCLUSION: VR simulator performance can be used as a gated, quantifiable performance goal to expert-level benchmarks. The EyeSi is a valid part-task training platform that may help develop novice surgeon dexterity to expert surgeon levels.