Comparative experience of phaco-I and kitaro eye models among ophthalmology trainees in Malaysia: A preliminary study.

Comparative experience of phaco-I and kitaro eye models among ophthalmology trainees in Malaysia: A preliminary study - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Indian J Ophthalmol . 2026 Apr 30;74(Suppl 1):S52–S58. doi: 10.4103/IJO.IJO_2721_25 Comparative experience of phaco-I and kitaro eye models among ophthalmology trainees in Malaysia: A preliminary study Ming Yean Ong 1, 2 , Chenshen Lam 1, 2, ✉ , Pei Rong Chiun 1, 2 , Teck Chee Cheng 1, 2 , Mae-Lynn Catherine Bastion 1, 2 Author information Article notes Copyright and License information 1 Department of Ophthalmology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2 Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia ✉ Correspondence to: Dr. Chenshen Lam, Department of Ophthalmology, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. E-mail: lamchenshen@ukm.edu.my Received 2025 Oct 25; Revised 2026 Feb 10; Accepted 2026 Feb 19; Issue date 2026 May. Copyright: © 2026 Indian Journal of Ophthalmology This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License (CC BY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. PMC Copyright notice PMCID: PMC13235806  PMID: 42060945 Abstract Purpose: To compare the user experience of Phaco-I and Kitaro among Malaysian ophthalmology trainees during phacoemulsification simulation. Secondary objectives included the preliminary validation of a questionnaire designed to assess internal consistency in simulation-based surgical training. Design: Cross-sectional questionnaire-based study. Methods: A cross-sectional study was conducted among 19 ophthalmology trainees participating in a phacoemulsification workshop. Each participant used both the Phaco-I and Kitaro, and then completed a 28-item validated questionnaire. The questionnaire comprised 20 items rated using a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree), two items assessing model preference, and six open-ended questions to obtain qualitative feedback. Data were analysed using Wilcoxon signed-rank test, and Cronbach’s alpha was calculated for reliability. Results: Kitaro scored significantly higher than Phaco-I across most domains, including surgical realism (median 4.00 vs 3.40, P = 0.011), skill development (median 4.25 vs 3.25, P = 0.002), confidence and skill transfer (median 4.00 vs 3.33, P = 0.0003), and overall experience (median 4.67 vs 3.00, P = 0.0003). Questionnaire reliability was excellent with Cronbach alpha coefficients exceeding 0.878. However, the interpretation of findings is limited by the small sample size. Conclusion: In this preliminary study, the Kitaro was perceived as offering a more realistic simulation experience for phacoemulsification training compared to Phaco-I. These findings highlight the potential utility of Kitaro for advanced simulation training among Malaysian ophthalmology trainees. Further studies with larger samples are needed to confirm these findings. Keywords: Education, Kitaro, ophthalmology training, phaco-I, phacoemulsification, simulation Simulation-based surgical training has emerged as a crucial component of ophthalmology education, providing trainees with a risk-free and safe environment to acquire important microsurgical skills. Cataract surgery, particularly phacoemulsification, requires a steep learning curve, making simulation training critical prior to live surgical exposure. Moving beyond the traditional Halstedian approach of ‘see one, do one, teach one,’ which may pose a risk to patient safety, simulation training offers a safer alternative by enabling trainees to acquire surgical skills in a controlled environment without involving actual patients. In Malaysian teaching hospitals, two wet lab eye models commonly used for phacoemulsification simulation are the Phaco-I (Phaco Practice Eye, Madhu instruments) and the Kitaro Wet Lab Eye (Kitaro). Understanding the differences in user experience and effectiveness between these models is vital for optimizing surgical training programs. Simulation plays an important role in enhancing hand–eye coordination, depth perception, and familiarity with surgical instruments. Research has shown that simulation-based training significantly reduces the rate of intraoperative complications and improves early surgical outcomes. A systematic review by Lee et al .[ 1 ] demonstrated that virtual reality and wet lab simulations increased operative confidence and technical skills among ophthalmology residents. Moreover, Laurell et al . and Chinnapat et al . also reported improved patient outcomes and reduction in the number of complications after simulation training, highlighting its role in early phacoemulsification learning.[ 2 , 3 ] The Phaco-I is developed and manufactured by Madhu Instruments Pvt. Ltd., based in New Delhi, India. It is a synthetic, training model that mimics human ocular anatomy, including anterior segments and lens nuclei. It is cost-effective and is being used in some of the Malaysian wet lab settings. In contrast, the Kitaro, developed by FCI Ophthalmics (France), offers enhanced anatomical realism with features such as simulated anterior chamber depth and realistic capsular behaviour. Its great realism makes it a preferred choice in international training workshops, although it is more expensive. Studies have consistently shown that the Kitaro provides a realistic simulation, especially regarding the anterior chamber depth, tactile feedback during capsulorrhexis, and hydrodissection response.[ 4 ] For instance, Penn State Health Milton S. Hershey Medical Centre implemented a cataract surgery training curriculum using the Kitaro, which received positive feedback for its realistic replication of the operating room experience and its accurate anatomical simulation.[ 5 ] In addition, several eye models are being developed by different companies, and a few studies have compared their effectiveness with the Kitaro, namely, the OrbiTau artificial eye, Farra Eye model, SimulEYE, and others, highlighting the global recognition of Kitaro as a high-quality simulator and the ongoing efforts to develop alternatives that either aim to surpass its performance or offer a more affordable option.[ 4 , 6 , 7 ] On the other hand, Phaco-I remains useful for foundational training and is praised for its ease of handling, practical utility in repeated practice, and affordability. Phaco-I has also been identified as one of the essential components for setting up a wet lab for ophthalmic surgical training, according to an article published in the Indian Journal of Ophthalmology, which supports its acceptability and effectiveness as a training simulator.[ 8 ] To date, there is limited published research directly comparing Phaco-I and Kitaro in Malaysian teaching hospitals. However, some informal surveys suggest a mixed preference. Many institutions favor Phaco-I for introductory training due to budget constraints, while Kitaro is reserved for advanced wet lab sessions. Key gaps include the absence of formal comparative studies between these two models in the Malaysian setting, lack of standardized validated tools for simulation evaluation, and limited data on how simulator training impacts actual surgical performance. Research is needed to determine which model offers the most benefit in the Malaysian context using validated assessment tools and outcome measures. In summary, phacoemulsification remains the foundation of cataract surgery, yet its steep learning curve poses significant challenges for trainees. Simulation-based training has emerged as an effective method to improve surgical proficiency in a risk-free environment. In Malaysian teaching hospitals, two commonly used wet lab simulators, namely, Phaco-I and Kitaro, are used to prepare ophthalmology residents before live surgery. However, there is a lack of local evidence comparing the trainee experience and perceived effectiveness of these two models. Given the need to optimize surgical training within budget constraints in Malaysian institutions, a comparative evaluation of these two simulators from the perspective of local trainees is both timely and essential. This study aims to fill that gap by providing evidence that can guide simulation model selection and improve phacoemulsification training quality in Malaysia. Methods This crosssectional study was conducted at the Department of Ophthalmology, Hospital Canselor Tuanku Mukhriz, Malaysia, during a structured phacoemulsification wet lab simulation workshop held from August 8 to August 9, 2025. A total of 20 ophthalmology trainees attending the phacoemulsification wet lab simulation workshop were invited to participate. Inclusion criteria included trainees who used both the Phaco-I and Kitaro during the workshop and provided informed consent. Trainees who did not complete simulations on both models or who withdrew consent were excluded. One participant was excluded from the study as he/she left the workshop early for personal reasons and was therefore unable to complete the phacoemulsification simulation steps using the Phaco-I. All participants performed core phacoemulsification steps using both the Phaco-I (Madhu Instruments Pvt. Ltd., New Delhi, India) and Kitaro (FCI Ophthalmics, France) during the workshop as shown in Fig. 1 . Hands-on practice covered essential surgical steps including capsulorrhexis, phacoemulsification, and intraocular lens insertion. Due to equipment limitations and station availability, a fixed sequence of exposure was utilized; all participants practiced on the Kitaro model first, followed by the Phaco-I model. To reduce fatigue and minimize potential learning effects, a mandatory 1-hour rest period was enforced between the two simulation sessions. Figure 1. Open in a new tab Images of the two eye models used in this study. (a) Kitaro model; (b and c) Phaco-I model A structured questionnaire was developed to assess user experience across four domains: surgical realism, skill development, confidence and skill transfer, and overall experience. The questionnaire consisted of 20 items rated on a 5-point Likert scale (1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, 5 = Strongly Agree), two questions regarding model preference, and six additional open-ended questions for qualitative feedback. Content validation was performed by three ophthalmologists with more than 2 years of surgical and simulation training experience. Face validation involved ten Year 4 postgraduate ophthalmology trainees familiar with phacoemulsification simulation. Due to the limited sample size, exploratory factor analysis (EFA) could not be performed as it requires a larger dataset to yield stable factor structures. Instead, internal consistency reliability of the questionnaire was assessed using Cronbach’s alpha, with α ≥ 0.70 considered acceptable. While these values confirm the internal consistency of the instrument, we acknowledge that they do not equate to formal construct validity. Hence, we view the results of this preliminary validated questionnaire as a foundational source for further refinement. We intend to conduct formal construct validation through EFA in future, larger-scale phacoemulsification workshops once the participant threshold required for such statistical power has been achieved. The preliminary validated questionnaire is shown in Table 1 . Table 1. The questionnaire following preliminary validation, assessed using a 5-point Likert scale Section Question Kitaro (1–5) Phaco-I (1–5) A. Surgical Realism Q1. The simulated eye’s anatomy closely resembled a real eye. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q2. Continuous circular motion was realistic in capsulorrhexis. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q3. Resistance and tear dynamics mimicked real capsule. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q4. Helped improve my skill in performing capsulorrhexis. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q5. The tissue manipulation during phacoemulsification felt similar to that of a real eye. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q6. The resistance and behavior of the lens cortex/nucleus felt similar to that of a real eye. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q7. Vacuum response and occlusion break were simulated well. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q8. Foot pedal control mimicked real-time surgical response. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q9. IOL* insertion and centration are adequately replicated. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q10. The simulator provided realistic feedback during surgical errors. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 B. Skill Development Q11. Improved my understanding of phacoemulsification steps. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q12. Enabled practice of different techniques (e.g., divide and conquer). ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q13. Improved my hand–eye–foot coordination. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q14. Allowed repetitive practice of difficult steps. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 C. Confidence and Skill Transfer Q15. The simulator increased my confidence to assist/perform real phacoemulsification. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q16. Skills learned from simulator are transferable to real-life surgery. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q17. Simulation reduced my anxiety about entering the operating room. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 D. Overall Experience Q18. The simulator was easy to use and operate. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q19. Suitable for beginner phacoemulsification training. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 Q20. I would recommend this simulator to fellow trainees. ☐1 ☐2 ☐3 ☐4 ☐5 ☐1 ☐2 ☐3 ☐4 ☐5 E. Preference and Overall Opinion Q21. Overall, which simulator do you prefer? Kitaro or Phaco-I Q22. Which simulator felt more realistic overall? Kitaro or Phaco-I F. Open-ended Feedbacks Q23. What are the strengths of Kitaro Eye? Open-ended answer Q24. What are the weaknesses of Kitaro Eye? Open-ended answer Q25. What are the strengths of Phaco-I? Open-ended answer Q26. What are the weaknesses of Phaco-I? Open-ended answer Q27. What would you suggest to improve Kitaro Eye as a training model. Open-ended answer Q28. What would you suggest to improve Phaco-I as a training model. Open-ended answer Open in a new tab * IOL=intraocular lens Demographic data including age, gender, and year of ophthalmology training were collected. After completing simulation on both models, participants independently rated their experience using the questionnaire administered electronically via Google Forms. The questionnaire was administered only once to each participant, during which all evaluation items were rated for both the Kitaro and Phaco-I models simultaneously. Data were analyzed using SPSS version 23. Descriptive statistics include participant demographics and questionnaire responses. Continuous data were presented as median with interquartile range (IQR), and categorical data as frequencies and percentages. The Wilcoxon signed-rank test was used to compare paired Likert scale scores between Phaco-I and Kitaro, given the nonparametric nature of the data and small sample size. Exact P values were reported, with P < 0.05 considered statistically significant. Cronbach’s alpha was calculated to assess the internal consistency of the questionnaire. Given the exploratory nature of this pilot study and the relatively small sample size, formal adjustments for multiple comparisons such as the Bonferroni correction were not applied. This approach was adopted to minimize the risk of Type II errors, which could obscure potentially meaningful trends in a preliminary investigation. Consequently, the P values are reported without adjustment and should be interpreted as preliminary findings intended to guide future, larger-scale validation studies. This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Universiti Kebangsaan Malaysia Research & Ethics Committee (Ethics code: JEP-2025-576). Consent was obtained via a Google Form, which included an explanation of the study’s purpose, procedures, potential risks, and benefits. They were also informed that participation was voluntary and that they could withdraw from the study at any time without penalty. Results Table 2 presents the demographic data of the participants. A total of 20 ophthalmology trainees were initially recruited for the study. One participant was excluded from the final analysis due to leaving early for personal reasons and was unable to experience using the Phaco-I. Therefore, the final dataset comprised responses from 19 participants. Table 2. Demographic profile of participants Variable n * (%) or Mean±SD † Number of participants 19 Age (years) 34.47±1.68 Gender Male 5 (26.3%) Female 14 (73.7%) Year in Ophthalmology Training Year 1 0 (0%) Year 2 8 (42.1%) Year 3 10 (52.6%) Year 4 1 (5.3%) Open in a new tab n * = number; SD † = standard deviation The mean age of participants was 34.47 ± 1.68 years. Of the 19 participants, the majority were female (73.7%), with most participants in their third year of ophthalmology training (52.6%). The sample size for this study (n = 19) was determined by the total capacity of a specialized phacoemulsification wet lab workshop, which was strictly limited to 20 participants to maintain a high instructor-to-student ratio and ensure adequate resource access. Our study enrolled 95% of the available cohort, providing a near-complete representation of trainees within this specific educational setting. Given the lack of existing comparative data on these models in Malaysia, this study is intentionally positioned as an exploratory and hypothesis-generating investigation rather than a confirmatory trial. While the current sample size limits the ability to generalize these findings globally, this study establishes a necessary preliminary baseline for the validation of surgical simulators within the Malaysian context. By positioning this work as an exploratory investigation, we provide the essential pilot data required for future researchers to perform formal power calculations and design larger, multicenter studies. This approach ensures that our preliminary results serve as a foundational step toward a standardized, evidence-based simulation curriculum in the region. The internal consistency of the questionnaire items was assessed using Cronbach’s alpha, which demonstrated high internal consistency across all domains with coefficients exceeding 0.878. While these values confirm the internal consistency of the questionnaire, we acknowledge that they do not equate to formal construct validity. Tables 3 and 4 summarize participants’ ratings of the Kitaro and Phaco-I simulators across individual items and four domains on a 5-point Likert scale, respectively. Table 3. Median Scores for Each Question (Likert Scale 1–5) Question Median (IQR*) P Kitaro Phaco-I Surgical Realism The simulated eye’s anatomy closely resembled a real eye. 4 (1) 3 (1) 0.090 Continuous circular motion was realistic in capsulorrhexis. 4 (0) 3 (1) 0.164 Resistance and tear dynamics mimicked real capsule. 4 (0) 3 (2) 0.137 Helped improve my skill in performing capsulorrhexis. 4 (0) 3 (1) 0.039* The tissue manipulation during phacoemulsification felt similar to that of a real eye 3 (1) 3 (1) 0.845 The resistance and behavior of the lens cortex/nucleus felt similar to that of a real eye 3 (1) 3 (1) 0.833 Vacuum response and occlusion break were simulated well 4 (1) 3 (1) 0.012* Foot pedal control mimicked real-time surgical response 4 (1) 3 (1) 0.012* IOL† insertion and centration are adequately replicated 4 (1) 3 (1) 0.003* The simulator provided realistic feedback during surgical errors. 4 (1) 3 (1) 0.134 Skill Development Improved my understanding of phacoemulsification steps. 5 (1) 4 (0) 0.011* Enabled practice of different techniques (e.g., divide and conquer). 4 (2) 3 (1) 0.100 Improved my hand–eye–foot coordination. 4 (1) 3 (1) 0.003* Allowed repetitive practice of difficult steps. 4 (1) 3 (1) 0.013* Confidence And Skill Transfer The simulator increased my confidence to assist/perform real phacoemulsification. 4 (1) 3 (1) 0.004* Skills learned from the simulator are transferable to real-life surgery. 4 (0) 3 (1) 0.016* Simulation reduced my anxiety about entering the operating room. 4 (1) 3 (1) 0.0001* Overall Experience The simulator was easy to use and operate. 4 (1) 3 (1) 0.001* Suitable for beginner phacoemulsification training 5 (1) 3 (1) 0.0003* I would recommend this simulator to fellow trainees 5 (1) 3 (1) 0.0004* Open in a new tab Results were statistically analyzed using the Wilcoxon signed-rank test. A P value of < 0.05 was considered statistically significant. IQR*=Interquartile range; IOL † =intraocular lens Table 4. Median scores for each domain Components Median (IQR*) P Kitaro Phaco-I Surgical Realism 4.00 (0.40) 3.40 (0.70) 0.011* Skill development 4.25 (0.75) 3.25 (1.00) 0.002* Confidence and Skill Transfer 4.00 (0.67) 3.33 (0.67) 0.0003* Overall Experience 4.67 (1.00) 3.00 (1.33) 0.0003* Open in a new tab Results were statistically analyzed using the Wilcoxon signed-rank test. A P value of < 0.05 was considered statistically significant. IQR*=Interquartile range Across all four domains, Kitaro received higher median scores compared to Phaco-I, with differences reaching statistical significance in every domain ( P ≤ 0.011). Kitaro achieved a higher overall realism score (median 4.00) than Phaco-I (median 3.40; P = 0.011). Statistically significant advantages were observed for improving capsulorrhexis skills ( P = 0.039), simulating vacuum response and occlusion break ( P = 0.012), foot pedal realism ( P = 0.012), and replicating IOL insertion and centration ( P = 0.003). Participants reported greater improvement in understanding phacoemulsification steps ( P = 0.011), enhancement of hand–eye–foot coordination ( P = 0.003), and opportunities for repetitive practice of difficult steps ( P = 0.013) with Kitaro. The overall skill development domain score was significantly higher for Kitaro (median 4.25) than for Phaco-I (median 3.25; P = 0.002). Kitaro was associated with significantly higher increases in self-reported confidence to assist or perform real surgery ( P = 0.004), perceived transferability of skills to live surgery ( P = 0.016), and reduction of preoperative anxiety ( P = 0.0001). The median of domain score was 4.00 for Kitaro versus 3.33 for Phaco-I ( P = 0.0003). Ease of use ( P = 0.001), suitability for beginner training ( P = 0.0003), and likelihood of recommending the simulator to peers ( P = 0.0004) were all rated significantly higher for Kitaro. The median of overall domain score was 4.67 for Kitaro compared with 3.00 for Phaco-I ( P = 0.0003). Table 5 summarizes the participants’ preferences and overall impressions of the two simulators. The majority of participants (94.74%) preferred the Kitaro over the Phaco-I simulator, with only one participant (5.26%) favoring the latter. In terms of perceived realism, 73.68% of participants felt that the Kitaro was more realistic overall, while 26.32% indicated a preference for the Phaco-I simulator. Table 5. Preference and overall opinion of participants Component Questions Kitaro Phaco-I Preference and Overall Opinion Overall, which simulator do you prefer? 18 (94.74%) 1 (5.26%) Which simulator felt more realistic overall? 14 (73.68%) 5 (26.32%) Open in a new tab Open-ended responses were analyzed to identify recurring themes on the strengths, weaknesses, and suggested improvements for both simulators. Participants frequently praised Kitaro Eye for its high anatomical resemblance to a real eye, especially the stability of the globe, realistic corneal wound manipulation, and clear visualization of the anterior capsule. The fixed position allowed for better wound construction, and the contrast between the capsule and lens was helpful for beginners. The most common criticisms related to the unrealistic lens properties, described as too soft, fragile, or sponge-like, making divide-and-conquer techniques difficult. A few mentioned that the continuous curvilinear capsulorrhexis (CCC) felt less realistic, with a “plastic” texture. Participants suggested increasing the density and thickness of the nucleus to allow proper hydrodissection, rotation, and cracking. Inclusion of lens cortex material was also recommended. Additional anatomical details, such as an iris or simulation of polar cataracts, were proposed for more comprehensive training. Phaco-I was praised for its realistic anterior capsule feel, the presence of a posterior capsule, and the tactile similarity of the lens to a real cataractous lens. Many participants appreciated the prominent red reflex and noted that capsulorrhexis, cracking, and phacoemulsification felt more authentic compared to Kitaro Eye. The main drawbacks included difficulty in cracking the dense nucleus, poor stability of the globe during use, and challenges with hydrodissection due to lens material entering surgical instruments. The premade main wound was criticized for causing excessive fluid leakage, while the anterior capsule was often described as too transparent and difficult to visualize without staining. The corneal surface was also reported as rigid or hazy in some cases. Common recommendations included enhancing the stability of the model, improving anterior capsule visibility through colouring, and avoiding premade corneal wounds. Participants suggested adjusting nucleus density to allow easier cracking while retaining realistic resistance and improving corneal clarity for better visualization. Discussion This study provides a direct comparison of user experience between two widely used phacoemulsification wet lab eye models, the Kitaro and Phaco-I, among ophthalmology trainees in Malaysia. Our findings demonstrate that the Kitaro model was favored over Phaco-I in multiple key domains including surgical realism, skill development, confidence and skill transfer, and overall user experience. These results, supported by both quantitative survey data and qualitative feedback, offer valuable insights to inform wet lab training program development in Malaysian ophthalmology education. To evaluate the simulators comprehensively, our study examined three distinct dimensions of medical education: face validity, educational usefulness, and user satisfaction. The Surgical Realism domain was utilized to establish face validity, assessing how accurately the models mimicked human ocular anatomy. Meanwhile, the domains of Skill Development and Confidence and Skill Transfer focused on perceived educational effectiveness. Finally, the Overall Experience domain captured user satisfaction, reflecting the trainees’ comfort and the models’ ease of use during the workshop. Consistent with prior international studies, Kitaro was rated significantly higher in surgical realism metrics, particularly in replicating capsulorrhexis skills, vacuum response, foot pedal control, and intraocular lens (IOL) insertion ( P values < 0.05). Although some anatomical realism items such as simulated eye anatomy similarity did not achieve statistical significance, trends consistently favored Kitaro, indicating more realistic tissue behavior and surgical feedback. This supported well with previous reports highlighting Kitaro’s anatomical realism and tactile feedback advantages over other simulators.[ 5 , 9 , 10 ] However, qualitative data revealed perceived limitations in Kitaro’s lens material, which participants described as too soft and fragile, making divide-and-conquer techniques challenging. The lack of posterior capsule and lens cortex simulation was also noted. These gaps reflect opportunities for further improvement in model design to enhance the realism of complex steps and complication management, essential for advanced trainee skill acquisition. The Kitaro model significantly improved self-reported understanding of phacoemulsification steps and hand–eye–foot coordination and enabled effective repetitive practice of difficult skills compared to Phaco-I (all P values < 0.05). These findings are important as improved psychomotor coordination is critical for safe cataract surgery outcomes. Additionally, participants reported greater confidence to assist or perform live phacoemulsification and higher perceived skill transferability with Kitaro, together with reduced preoperative anxiety. This confirms the role of high realistic simulation not only in psychomotor training but also in strengthening trainee readiness and reducing operating room stress, consistent with findings from Laurell et al . and Chinnapat et al .[ 2 , 3 ] Participants’ overall rating of usability, suitability for beginner training, and willingness to recommend the simulator were also significantly higher for Kitaro. The strong preference (95%) and perceived realism (74%) favoring Kitaro highlight its acceptance as the superior training tool in this study’s Malaysian trainee cohort. Consistent with our findings, Belyea et al .[ 11 ] reported that residents who underwent simulator-based training achieved shorter phacoemulsification times, used lower percentage power, experienced fewer intraoperative complications, and progressed along the learning curve more rapidly, further supporting the role of simulation in enhancing surgical efficiency and safety. This contrasts with certain settings where budget limitations drive more frequent use of lower-cost models like Phaco-I. Despite its lower ratings, Phaco-I was appreciated for its realistic anterior capsule feel, presence of posterior capsule, and authentic lens resistance in some aspects. The identified weaknesses such as model instability, corneal clarity issues, and premade wound limitations should provide actionable recommendations for manufacturers and institutions using Phaco-I. Given the steep learning curve of phacoemulsification surgery and the imperative to ensure patient safety, our findings highlight the importance of using higher fidelity models like Kitaro for advanced wet lab training, where realism directly enhances skill acquisition and confidence. At the same time, Phaco-I’s affordability and foundational training value should not be dismissed, particularly for novice trainees and resource-limited contexts. Institutions may consider optimizing training curricula by employing a staged approach and initial basic skills with Phaco-I, progressing to advanced simulation with Kitaro for refinement and confidence building. This study has limitations. The small sample size and single-center design may limit generalizability. Although the questionnaire showed good internal consistency in this preliminary study, it would benefit from further refinement and validation in a larger cohort. As with most simulation surveys, the study depended on participants’ self-reported perceptions rather than objective assessments of surgical skills. Future research should incorporate objective skill assessment, namely, Objective Structured Assessment of Technical Skills (OSATS), International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubric (ICO-OSCAR), or blinded faculty grading, as the present findings reflect user preference rather than confirmed skill acquisition. We acknowledge that the fixed order of simulator exposure (Kitaro followed by Phaco-I) presents potential confounding factors, specifically learning and fatigue effects, where skills acquired on the initial model could have influenced perception or performance on the subsequent one. Ideally, such confounders would be mitigated through a randomized crossover design via computer-generated randomization to alternate the starting model. In the present study, we attempted to minimize these confounding factors by incorporating a standardized 1-hour rest period between sessions to reduce the immediate impact of fatigue, though we recognize that a randomized approach would have provided stricter control over order bias. Improvements in simulator technology to address the weaknesses such as improved lens density and posterior capsule simulation in Kitaro and increased model stability and corneal clarity in Phaco-I will be critical for further advances. Additionally, developing cost-effective, highly realistic models tailored for Malaysian training needs remains a priority. With the rapid pace of technological advancement in ophthalmic surgery and simulation, the optimum training methods are expected to evolve continuously in the near future. As new simulation platforms, virtual reality, and surgical adjuncts emerge, it will be essential to regularly review, update, and selectively adopt training modalities to ensure the highest quality of surgical education. The constant update and improving training strategies with technological developments will help optimize learning curves, enhance surgical safety, and improve patient outcomes. In this context, the preliminary validated questionnaire developed in the present study may serve as a useful reference tool for future, larger-scale research, facilitating systematic evaluation and comparison of evolving training or simulation methods. Conclusion This study suggests that, among Malaysian ophthalmology trainees, the Kitaro wet lab eye model was perceived to offer higher surgical realism, skill development, confidence building, and overall user experience compared to Phaco-I. While both models offer valuable training opportunities, the higher realism of Kitaro was viewed as particularly advantageous for advanced skill acquisition, whereas Phaco-I retains utility for foundational practice, especially in resource-limited settings. Addressing the identified weaknesses of each model will further enhance their educational value. Given the rapid pace of technological advancement in surgical simulation, training curricula should remain adaptable, incorporating regular evaluation and selective adoption of emerging methods. The preliminary questionnaire developed in this study offers a practical tool for future large-scale evaluations, helping to guide the continuous refinement of simulation-based cataract surgery training. Ethical approval Ethical approval was obtained from the Universiti Kebangsaan Malaysia Research & Ethics Committee (Ethics code: JEP-2025-576). Data availability The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Authors’ contributions Concept and Design: Mae-Lynn Catherine Bastion, Chenshen Lam, Ming Yean Ong; Definition of Intellectual Content: Mae-Lynn Catherine Bastion, Chenshen Lam, Ming Yean Ong; Literature Search: Ming Yean Ong; Clinical Studies: Ming Yean Ong, Pei Rong Chiun; Experimental Studies: Ming Yean Ong, Pei Rong Chiun; Data Acquisition: Ming Yean Ong, Pei Rong Chiun; Data Analysis and Statistical Analysis: Ming Yean Ong, Teck Chee Cheng; Manuscript Preparation: Ming Yean Ong; Manuscript Editing: Chenshen Lam, Ming Yean Ong; Manuscript Review: Mae-Lynn Catherine Bastion, Chenshen Lam, Ming Yean Ong. Conflicts of interest There are no conflicts of interest. Acknowledgements The authors would like to express their sincere gratitude to Dr. Othmaliza Othman, Prof. Madya Dr. Wan Haslina Wan Abdul Halim, Dr. Noor Widyani Ahmad Shahaime, Dr. Wan Farah Amirah binti Wan Azlan, Dr. Jesspreet Kaur A/P Harban Singh, Dr. Husna Azmi, Nurul Shahida Shaari, and Wan Norasyikin binti Wan Hassan for their invaluable support and contributions in organizing the phacoemulsification workshop and wet lab. Their dedication and assistance were instrumental in ensuring the smooth conduct of the workshop, which enabled the successful completion of this study. Funding Statement Nil. References 1. Lee R, Raison N, Lau WY, Aydin A, Dasgupta P, Ahmed K, et al. A systematic review of simulation-based training tools for technical and non-technical skills in ophthalmology. Eye. 2020;34:1737–59. doi: 10.1038/s41433-020-0832-1. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Laurell C-G, Söderberg P, Nordh L, Skarman E, Nordqvist P. Computer-simulated phacoemulsification. Ophthalmology. 2004;111:693–8. doi: 10.1016/j.ophtha.2003.06.023. [ DOI ] [ PubMed ] [ Google Scholar ] 3. Chinnapat M, Adisak T, La-Ongsri A. Effect of surgical simulation training on the complication rate of resident-performed phacoemulsification. BMJ Open Ophthalmol. 2022;7:e000958. doi: 10.1136/bmjophth-2021-000958. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Raval N, Hawn V, Kim M, Xie X, Shrivastava A. Evaluation of ophthalmic surgical simulators for continuous curvilinear capsulorhexis training. J Cataract Refract Surg. 2022;48:611–5. doi: 10.1097/j.jcrs.0000000000000820. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Wright C, Scott IU, Callahan C, Papachristou GC, Khalifa Y, Pantanelli S. Implementation of a Model Eye (Kitaro) Based Cataract Surgery Training Curriculum. Invest Ophthalmol Vis Sci. 2016;57:938. [ Google Scholar ] 6. Cândido T, Pineda R, Rossi S, Lanza JVM, Kara-Júnior N. Simulated phacoemulsification training using the OrbiTau artificial eye: Experience at a single institute. Arq Brasil Oftalmol. 2025;88:e20240084. doi: 10.5935/0004-2749.2024-0084. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Nursanti HR, Dewi BJ, Syska W, Faraby M, Khoe LC. Face and content validity of farra eye model as a surgical simulator for capsulorhexis training. J CME. 2025;14:2467566. doi: 10.1080/28338073.2025.2467566. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 8. Mishra D, Bhatia K, Verma L. Essentials of setting up a wet lab for ophthalmic surgical training in COVID-19 pandemic. Indian J Ophthalmol. 2021;69:410–6. doi: 10.4103/ijo.IJO_3298_20. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 9. Alwadani S. Cataract surgery training using surgical simulators and wet-labs: Course description and literature review. Saudi J Ophthalmol. 2018;32:324–9. doi: 10.1016/j.sjopt.2018.01.003. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 10. Khalifa YM, Hines MA, Gearinger M. The future of surgical assessment. Br J Ophthalmol. 2012;96:1145. doi: 10.1136/bjophthalmol-2012-301588. [ DOI ] [ PubMed ] [ Google Scholar ] 11. Belyea DA, Brown SE, Rajjoub LZ. Influence of surgery simulator training on ophthalmology resident phacoemulsification performance. J Cataract Refract Surg. 2011;37:1756–61. doi: 10.1016/j.jcrs.2011.04.032. [ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. 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