Impact of extended reality (XR) simulation on ophthalmology training outcomes: an updated systematic review and meta-analysis

Background Extended reality (XR) simulation offers repeatable, risk-free practice for ophthalmic training. We conducted a systematic review and meta-analysis to quantify its effects on training outcomes. Methods We searched MEDLINE (PubMed), Embase, Web of Science Core Collection, and Cochrane CENTRAL from inception to February 6, 2026. Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (non-randomized studies), and certainty of evidence was evaluated with GRADE. Statistical analysis was performed using Stata 15. Results Thirty-two studies (1,572 trainees) were included. XR training significantly reduced overall intraoperative complications (OR = 0.72; 95% CI, 0.63–0.82; P < 0.001), posterior capsule rupture (OR = 0.63; 95% CI, 0.49–0.81; P < 0.001), and CCC-related complications (OR = 0.44; 95% CI, 0.21–0.90; P = 0.024). Vitreous loss and retained lens material did not differ significantly. Technical performance improved, with higher global surgical scores (SMD = 1.93; 95% CI, 1.49–2.38; P < 0.001) and CCC scores (SMD = 0.73; P < 0.001). Total operative time was significantly shortened (WMD = −8.92 min; 95% CI, −16.38 to −1.46; P = 0.019). Trainee confidence generally improved, though perceived realism varied. Conclusions Extended reality (XR) simulation training can enhance ophthalmic surgical technical performance and procedural efficiency, reduce the risk of intraoperative complications, and improve trainees' operative confidence. These findings provide an evidence-based foundation for the design and optimization of ophthalmology training curricula. Future studies should further investigate the value of XR technologies in non-cataract procedures and in the development of non-technical skills. Systematic trial registration https://www.crd.york.ac.uk/prospero/ , identifier: CRD420261288204.