The role of extended reality in optometry education: a narrative review

ABSTRACT

The evolution of digitally based pedagogies, such as extended reality (XR) – a group of simulated learning environments that include virtual simulation, virtual reality, and augmented reality – has prompted optometry educators to seek evidence to guide the implementation of these teaching and learning activities within their curricula. Looking more broadly across the medical and allied health fields, there is a wealth of evidence to guide the incorporation of XR, as it is increasingly being integrated into the curricula of other select health professions disciplines. Educators from these disciplines continue to explore and embed XR in practice. This narrative review summarises the findings and appraises the literature on the use of XR in optometry education. It identifies the learning domains in which XR has been implemented in optometry education and proposes areas for further investigation. The review questions the technology-focused approach that has driven the literature within the review and calls for richer pedagogical foundations with suggestions for future research agendas. As such, this narrative review provides optometry educators with new ways of understanding XR and its relationship with the curriculum.

KEYWORDS:

• Augmented reality
• health profession education
• online learning
• optometry education
• simulation-based education
• virtual reality
• virtual simulation

Introduction

Preparing students to be future health practitioners equipped for the dynamics of professional practice is difficult in classroom activities that are tightly controlled and placements that can be uncertain.¹ Structured lesson plans in classrooms expose learners to expert knowledge and practices, though they can lack the intricacies needed to prepare learners for the complexities of professional work.¹ Placements within the workforce are intended to develop the ability of learners to apply theory to practice in authentic learning environments.¹ By their nature, placements are opportunistic, and aside from requiring considerable effort, resources and financial burden, they can negatively impact the learning journey.²

Some learners report discrimination, feeling overwhelmed, feelings of being ignored by mentors and perceive that experiences on placement can be inequitable.^3–5 Extended reality (XR) is one method of simulation-based education that offers a bridge between the confines of the classroom and fluidity of placement, which can also provide learners opportunities for practice in clinically replicated environments that are supported by pedagogical frameworks and learning theories.⁶

The integration of XR within Health Professional Education (HPE) represents a dynamic and evolving area of interest to educators and researchers. Recently, educational technology has become more accessible, leading to an increase in adoption and exploration of embedding this within the curriculum.⁶ This surge in HPE implementing XR is largely attributed to the well-reported advantages that include: patient safety; the opportunity to learn in low-stakes environments; the use of standardised patient presentations; and the circumvention of traditional constraints, such as time and space.^7–9 Furthermore, from a financial perspective, XR presents a cost-effective alternative to traditional mannequin-based simulations.^10,11

XR can incorporate competence indicators, peer review, prompts and self-reflection, as well as more effectively prepare learners for their professional lives than traditional placements.^6,12 Add to this additional options for assessment, and individualised learning and exposure to diverse clinical experience, XR becomes an attractive prospect for HPE.^13,14 However, the impact of these potential benefits is contingent upon considered design, technology choices and human resources.

Optometry education, like other HPE curricula, requires developing learners to be able to enact and sometimes react as clinical practice unfolds in unanticipated ways.¹ The curriculum is designed to support developing learners by placing them in an environment that exposes them to the routines and expectations of everyday clinical practice.¹⁵ Traditionally, this has been structured around didactic lectures that impart foundational knowledge, reinforced through laboratory or practical-based learning activities and clinical placements.¹¹ Digital learning has been in optometry curricula from as early as 1976 and has seen accelerated growth due to the impact of remote learning during the pandemic.^16–18 It is only in recent years that the potential benefits that XR could bring to optometry education have been explored.

This narrative review examines the literature to elucidate the extent of the research conducted to explore XR in optometry education. Initially, the review discusses the definitions and taxonomy of XR and critically examines educational strategies guiding the adoption of XR in HPE. This forms the foundation for this narrative review before subsequently discussing 16 key studies and proposing strategies for the implementation of XR pedagogy within optometry education.

Elucidating the taxonomy of XR

Immersive technology emerged in the 1960s, since which there have been many diverse taxonomies.¹⁹ XR is an umbrella term for environments that provide a sense of immersion and presence.^20–22

Virtual reality is set in a virtual environment where computerised technology creates a three-dimensional world that contains virtual elements such as person, event or object.^20,22,23

Virtual simulation is set in a virtual environment supported by a computer, tablet or phone screen and controlled by a person, for example web-based scenarios.^22,23

Augmented reality is set in a physical environment with virtual elements overlayed using computerised technology and controlled by a person.^20,22,24

Physical Reality is set in a physical environment in real time physical reality.

As a group of optometry educators, digital learning practitioners and higher education researchers, the authors have adapted the spectrum of reality-virtuality continuum to visualise the definitions of XR applied in this review in Figure 1.²⁴

Figure 1. Adaptation of the spectrum of reality-virtuality. The continuum of extended reality extends from the physical environment to the virtual environment.²⁴

Pedagogical approaches for XR in HPE

Research has identified the affordances of implementing XR as a form of simulation-based education, advocating for alignment with other pedagogical approaches, learning theories and theoretical frameworks.^25,26 Several associations of health professions and researchers have developed standards for simulation to promote the evidence-based incorporation of XR pedagogies:

• In nursing education, the International Nursing Association for Clinical Simulation and learning provides authoritative standards for best practice.^25,26

• Physiotherapy researchers conducted a literature review to inform the development of the Integrated Simulation and Technology Enhanced Learning framework. This framework outlines theoretical practices and perspectives to inform preparation, intervention and evaluation.²⁷

• The Association for Medical Education in Europe has published a guide emphasising practical applications of simulation-based education.²⁸

• In speech pathology education, authors have delineated processes and considerations essential to simulation-based education, which have been referred to in XR research.^29,30

Notably, in optometry education research and practice there is an absence of such guidelines. This narrative review therefore draws on a framework that was designed to inform broader educational practice for simulation-based education in HPE.^31,32 The widely used framework consists of six phases of simulation which will be referred to in this review: preparation, briefing, simulation activity, feedback and debriefing, reflecting, and evaluating.^31,32 The preparation phase includes all the activities prior to briefing the learners such as defining the learning needs, consultation with stakeholders and other elements.³¹ Briefing orientates learners to the learning activity.^15,32

The simulation activity phase itself encompasses learning participating in the simulation.³² The feedback and debriefing phase explores the experiences of learners and prompts reflection.^25,31,32 Reflection and feedback have their own phases but are recognised as occurring throughout the simulation. Evaluation involves summative or formative proformas for the attainment of learning outcomes.^25,31,32

These standards and frameworks inform the instructional design of XR, in combination with other pedagogical approaches such as experiential learning, deliberate practice and mastery learning.^33–38 While an in-depth discussion of these is beyond the scope of this narrative review, the following section provides insight with examples.

Experiential learning

Experiential learning conceptualises learning as a dynamic process; a process through which concepts are not simply acquired as knowledge, they are derived and internalised from the experience and continually reshaped from reflection on the experience.^36,39 In HPE, this manifests as lifelong learning strategies, kinaesthetic activities, workplace learning, scaffolding, situated learning, service learning and cognitive apprenticeship.³⁶ These processes can capitalise on XR to expose the learner to authentic, situated clinical experiences that immerse the learner in realistic patient care.³⁶ Scenarios in XR provide the learner with exposure to complex experiences similar to that experienced in authentic health professional practice.³⁶

Deliberate practice

Deliberate practice provides learners with multiple opportunities to acquire a skill and aim for performing skills automatically.⁴⁰ It is best used when there are clear performance guidelines and specific scripting.⁴¹ The process allows application, evaluation and feedback on particular competencies.³⁴ An extension of deliberate practice, Rapid Cycle Deliberate Practice, is particularly influential on reinforcing specific competencies within a timeframe.⁴¹ XR offers an avenue for deliberate practice as learners have repeated opportunities for skill development and gain specific feedback.⁴²

Mastery learning

Mastery learning emphasises competency-based education that focuses on the performance of developing learners to a predetermined standard to be awarded mastery.³³ This requires clear objectives for sequenced development of skills and formative practice with feedback as part of the instructional design.³³ This has been implemented with learners using XR to develop specific competency skills such as central vein catheter injections.³⁵

The integration of these approaches in curricula, while vital, are not sufficient in isolation to lead to learning with XR.⁴³ Evidence-based practice requires the thoughtful and co-ordinated application of standards, frameworks, and learning theories to guide the use of XR in optometry education.

Grounding for the review in optometry education

In optometry education, there has been a notable escalation in the use of technology following the events of the global pandemic in 2020, which required closure of physical campuses and interruptions to face-face teaching.^44–46 In response to these challenges, optometry schools sought out innovative ways to use technology to provide remote, online or blended teaching methods.^45,47 This shift not only supported the continuation of education, but opened avenues to improve and restructure optometric education.^45,47 Furthermore, the profession adapted with an accelerated provision of adopting healthcare virtually, such as teleconferencing.⁴⁴

Simultaneously, there is an emerging body of research dedicated to the development of XR to diagnose and manage ocular conditions, increasing the relevance of XR to the future professional role of optometrists.⁴⁸ Despite growing professional and educational interest in XR in the optometry discipline, to our knowledge there has been no narrative review of the literature conducted to date. This observation underscores a significant gap in the current practice and scholarship of optometry education.

Aim

With the growing interest in XR and an anticipation of limited scholarly work on specific types of immersive experiences, this review aims to comprehensively describe and synthesise the literature regarding the role of XR in optometry education. This review addresses this aim by answering the following research questions:

1. In which learning domains has XR been employed in optometry education?

2. What are the pedagogical designs informing XR learning experiences educators provided?

3. To what extent does XR influence learning in optometry education?

4. How can findings from the literature inform future experimental and applied practice in optometry education?

Approach

This review focuses on the educational research in optometry education using XR. A narrative review was chosen to explore the literature broadly, describe the development of XR in optometry education and provoke thought rather than provide a systematic critical appraisal of the literature.^49,50

Literature search

The literature search was completed following the principles outlined in the Scale for the Assessment of Narrative Review Articles.⁵⁰ After an initial exploratory literature search, specific criteria for the search were developed to identify publications focussing on the role of XR specifically in optometry education. The criteria for the review were: (1) research publishing primary data in a peer reviewed journal between January 1976 and December 2023; and (2) research in the context of optometry or optometry education.

Studies were excluded based on the following criteria: (1) studies presented at an academic conference (non-peer reviewed) or unpublished thesis; (2) a review, meta-analysis or systematic review; (3) studies on ophthalmology training in a postgraduate medical degree; (4) studies that did not mention the term virtual reality, virtual world, augmented reality, or virtual simulation with optometry education.

MEDLINE, ProQuest Central, Journal@OVID, Wiley, and Scopus were searched in December 2023. The following terms were used in the search of full text: ‘virtual reality-based education’, ‘virtual reality’, ‘virtual world’, ‘virtual simulation’, ‘optometry education’, ‘health professional education’, ‘optometry’ combined with ‘virtual reality-based education’, ‘virtual reality’, ‘virtual world’, ‘virtual simulation’, ‘virtual patient’ and ‘simulation-based education’.

The search was limited to publications from the year 1976 to include fundamental concepts of virtual reality-based education. The search was expanded to include recent papers that cited the original publications and back-tracking of references.⁵¹ Publications were added if they enhanced conceptual understanding until theoretical saturation was reached.⁵²

Discussion

Study descriptions

A total of 32 papers identified from the search strategy with 16 excluded after reading the full text. The earliest study included was published in 2014. A summary of the research aims, methodology, outcomes and sample details for all 16 studies are provided in Table 1. In the studies that were included in the literature review, XR simulations were augmented reality, virtual reality, or virtual simulation.

Table 1. Summary of literature describing XR using in optometric training.

Author, country	Research aim	Methodology	Outcomes	Sample	Research subject	Year level	XR type
Wei et al.^Citation53 Australia.	To propose two revised setups for optometry training simulation.	Cross-sectional	Clinical skills performance of slit-lamp examination; Learner satisfaction	10	Learners	Not mentioned	augmented reality
Woodman^Citation11 Australia.	To explore the influence of short-term exposure to a virtual refractor on optometry learner clinical subjective refraction outcomes using a real patient; how learners interacted with a virtual refractor.	Quasi-experimental	Clinical performance of subjective refraction; Self-reported confidence.	40	Learners	4^th-5^th	virtual simulation
Yi^Citation54 China.	Improving teaching quality; stimulating learning interest and realising teaching interaction with three-dimensional simulation.	Case study	Knowledge.	–	Learners	–	virtual simulation
Anderson et al.^Citation55 USA.	Report the impact on live binocular indirect ophthalmoscopy skills assessment, learner and faculties perceptions of augmented reality.	Retrospective cohort	Clinical skill confidence; Clinical skills performance of BIO.	–	Learners & Educators	2^nd	virtual reality
Alhazmi et al.^Citation18 Australia.	To observe the translational effects of virtual refraction after implementation early in an optometric program.	Randomised control trial	Clinical performance of subjective refraction; Clinical skill confidence; Self-perceived knowledge	24	Learners	1^st	virtual simulation
Pancholi and Dune^Citation56 USA.	The effect of virtual patient instruction on the accuracy of self-assessment of clinical skills.	Cohort	Knowledge; Confidence.	195	Learners	2^nd	virtual simulation
Isikguner and Umaefulam^Citation57 UK/Canada.	To turn RedEye into a fully packaged software/game to be used by the teaching staff as a teaching and learning tool.	Case study	Development of a three-dimensional virtual simulation.	–	–	–	virtual simulation
Adams and Wyles^Citation16 USA.	To describe the distance learning methodology with simulated patients.	Case study	–	–	Learners	2^nd- 3^rd	virtual simulation
Chu et al.^Citation58 USA.	To evaluate whether these learners were able to perform binocular indirect ophthalmoscopy to a competent level following 10 weeks of independent study with the Eyesi® Indirect Ophthalmoscope.	Quasi-experimental.	Clinical skills performance of BIO.	–	Learners	1^st	virtual simulation
Douglass et al.^Citation59 Australia.	To examine the effect of using the Eyesi® Indirect Ophthalmoscope simulator on the performance, theoretical understanding, and confidence of learners relative to traditional teaching of binocular indirect ophthalmoscopy; to examine the utility of the simulator in continuing professional development for optometrists.	Quasi-experimental.	Clinical skill confidence; Clinical skills performance of BIO; Knowledge.	41 (n = 30 learners; n = 11 optometrists)	Learners & Optometrist	1^st	virtual reality
Edgar et al.^Citation60 Australia.	To investigate pre-clinical optometry learners’ acceptance of virtual simulation for learning and the perceived effect on the development of cognitive and affective skills as core professional competency skills.	Cross-sectional	How learners perceive virtual simulation; Perceived improvement in cognitive and affective skills.	51	Learners	1^st	virtual simulation
Mohr^Citation17 USA.	Discusses the adaptation of clinical programs during the pandemic to remote learning.	Discussion	–	–	–	–	virtual simulation
Cham, et al.^Citation46 Australia	To explore the value of utilising non-immersive virtual reality to create virtual learning environments to support and prepare optometry students in their transition into preclinical and clinical teaching spaces.	Cross-sectional	How learners perceive virtual learning environments.	93	Learners	1^st-4^th	virtual simulation
Edgar, et al.^Citation61 Australia & India.	To evaluate the impact of the international eyecare community platform’s virtual simulated international placements in optometric education.	Cross-sectional	How learners and educators perceive virtual simulation; perceived improvement in cognitive and affective skills; scores on the Diagnostic Thinking Inventory for Optometry.^Citation62	70 (n = 64 learners; n = 6 educators)	Learners & Optometry educators	2^nd- 5^th	virtual simulation
Doron et al.^Citation63 Israel.	To evaluate the effectiveness of online teaching and virtual patient experience in improving learner’s competency to reflect on their patient experiences.	Cross-sectional	Groningen Reflection Ability Scale^Citation64; Reflective practice.	104	Learners	2^nd	virtual simulation
Edgar, et al.^Citation65 Australia & India.	To identify the key concepts that contribute to an inclusive learning environment using virtual simulation for virtual simulated international placements.	Cross-sectional	How learners and educators perceive virtual simulation; scores on the Systems Usability Scale.^Citation66	70 (n = 64 learners; n = 6 educators)	Learners & Optometry educators	2^nd- 5^th	virtual simulation

Learning domains (RQ1)

Training technical skills

As with learners from other HPE disciplines, optometry graduates are required to demonstrate the ability to perform clinical examinations efficiently and safely.⁶⁷ This narrative review found the following specific uses of XR for developing technical skills training of learners in optometry education.

Binocular vision assessment

An open access Strabismus Simulator⁶⁸ by the American Academy of Ophthalmology was available at the time of this review. No studies that met the criteria for this review included technical skills training for binocular vision assessment.

Slit lamp examination technique

A study by Wei et al.,⁵³ reported on the design of an inhouse augmented reality prototype to train learners in optometry courses to use a slit lamp and recognise pathology. This employed an in-house developed slit lamp with view control interaction accompanied by forced feedback.⁵³ No further studies on slit lamp examination technique in optometry education were identified in this review.

Refraction technique

The Brien Holden Vision Institute (BHVI) virtual refractor has been using to train learners for over 20 years. Studies have investigated the use of this learning activity to improve accuracy and efficiency in refraction during patient encounters.^11,18 This simulates a subjective refraction assessment using a phoropter on a random or pre-determined patient. It offers variations in clinical scenarios (age and refractive error type).¹¹ One study provided participants with multiple opportunities to use the virtual refractor as a clinical placement over a summer break for 4^th and 5^th year learners.¹¹ Another incorporated the virtual refractor into the learning activities within the curriculum for 1^st year learners.¹⁸

Retinoscopy

An open access retinoscopy simulator⁶⁹ by the American Academy of Ophthalmology was available at the time of this review. No studies that met the criteria for this review included technical skills training for retinoscopy.

Binocular indirect ophthalmoscopy

Three studies explored the implementation of Eyesi® Indirect Ophthalmoscope virtual reality training equipment in the context of optometry education.^55,58,59 This technology is designed to train performing binocular indirect ophthalmoscopy (BIO) with the participant wearing a headset and viewing renderings of anatomical structures of the retina.⁵⁸ The training has four sequential modules integrated into the virtual reality training.⁵⁸ One study embedded this in the curriculum for 2^nd year learners,⁵⁵ another implemented the Eyesi® Indirect Ophthalmoscope virtual reality training to introduce BIO training earlier in the curriculum with 1^st year learners.⁵⁸ The third study took a quasi-experimental approach and recruited participants that were 1^st year learners and qualified optometrists to evaluate the equivalence of physical reality to virtual reality training.⁵⁹

Direct ophthalmology

The Eyesi® Direct Ophthalmoscopy training technology has been investigated⁷⁰ and an in-house virtual reality technology⁷¹ was also reported in an evaluation study in medical education to train direct ophthalmoscopy skills. No studies identified in this review incorporated direct ophthalmoscopy training with XR in optometry education.

Training non-technical skills

Optometry graduates are also required to be competent in non-technical skills.¹⁵ The non-technical skills are mentioned in several of the studies in this narrative review. For example, one study used virtual simulation with 2^nd year learners to develop self-evaluation skills.⁵⁶ Another implemented virtual simulation with 2^nd year learners to train reflective skills.⁶³ Several studies focus on the development of the aspects of clinical reasoning in virtual simulation through practicing clinical tasks such as taking a patient history, test selection, data interpretation and arriving at a diagnosis.^16,17

Non-technical skill development were a focus of one study with 1^st year learners using virtual simulation embedded into the curriculum that aimed to develop clinical reasoning, patient-centred care, evidence-based practice and communication skills.⁶⁰ Another international study with 2^nd to 5^th year learners extended on this and evaluated the development of diagnostic reasoning skills.⁶⁰

Three dimensional replications of ocular anatomy have been developed to support clinical knowledge development in optometry education.⁷² A case study discussed the creation of a virtual simulation game that replicates the appearance of pupillary reflex to demonstrate the effects of disease on anatomy and optics of the eye.⁵⁷ Another case study reports on the development of a model to use in teaching retinoscopy theory to learners.⁵⁴ These approaches both involve the use of three-dimensional virtual simulation for visualisation, enabling learners to conceptualise knowledge for difficult points of comprehension that cannot be modelled clinically.

Alternatively, discipline-specific knowledge training was referred to by two studies incorporating XR technology designed to train technical skills. One study referred to training discipline-specific knowledge using the Eyesi® Indirect Ophthalmoscope⁵⁹ while another referred to improving self-perceived knowledge using the BHVI virtual refractor.¹⁸

In HPE, one of the purposes of simulation-based education is to increase exposure to clinical experiences.⁶ It has been used as a resource to prepare learners for clinical environments.⁴⁶ Virtual simulation has also been discussed as being a way to prepare 1^st year learners to understand the scope of practice in optometry by exposing them earlier to clinical settings.⁶⁰ One study expanded on these findings to introduce virtual simulated international placements in optometry education and allowed for an exposure to international clinical practice for learners.⁶¹

Pedagogical design (RQ2)

Intervention characteristics

The technological attributes of XR used in these studies are summarised in Table 2. Augmented reality was used in a study involving training skills with a slit lamp prototype.⁷¹ The remaining studies, by our definitions, either used virtual simulation (n = 8) or virtual reality (n = 6). Videoconferencing software was used in most of the virtual simulation studies. Over half of the studies described the interactions of participants with XR as two-way, such as automatic computerised responses to the inputs of learners.

Table 2. Technology attributes.

Category	Contents	Number of studies
Modality	Virtual reality	6
	Virtual simulation	9
	Augmented reality	1
Participant interaction	One-way	5
	Two-way	10
	Not mentioned	3
Participant representation	Screen (control via mouse, joystick)	9
	Voice	3
	First Person (control via infrared or haptic input)	4
	Script	2
Platform type	Eyesi® Binocular Indirect Ophthalmoscope	3
	BHVI Virtual Refractor	2
	Slit lamp simulator	1
	RedEye	1
	Videoconferencing software	6
	Website based	5
	Not mentioned	2

Most learners were able to represent themselves through interaction with a screen-based input such as a computer mouse. Others required embodied representation of the learners as they performed tasks representing ‘self’ wearing virtual reality headsets, motor or sensory inputs. Notably, Table 2 displays a greater number of studies than the 16 that met the inclusion criteria as some studies addressed multiple criteria.^60,61,65 Those implementing XR for technical skills development included commercialised products apart from one study that incorporated an in-house AR solution.

Learning theory

A summary of pedagogical attributes of these studies can be found in Table 3. Five of the studies referred to learning theories in describing the XR intervention, and three provided explanatory detail on how they were incorporated into the XR.^60,61,65 One study by Isikguner et al. referred to learning with technology for educational games as experiential learning.⁵⁷ The theoretical framework of that study was based on self-determination theory, a theory of intrinsic motivation based on the concepts of competence/mastery, autonomy and relatedness/belonging.⁵⁷ In another study, scaffolding of experiential learning was discussed.⁶⁰ A different study referred to deliberate practice for training practical skills using the Eyesi® binocular indirect ophthalmoscope.⁵⁸

Table 3. Pedagogical attributes summary.

Category	Contents	Number of studies	Study
Theory	Yes	5	^Citation57,Citation58,Citation60,Citation61,Citation65
	Not mentioned	10	^Citation11,Citation16–18,Citation46,Citation53–56,Citation59,Citation63
Learning outcomes	Yes	5	^Citation55,Citation56,Citation60,Citation61,Citation65
	Not mentioned	10	^Citation11,Citation16–18,Citation46,Citation53–56,Citation59,Citation63
Teaching method	Passive learning	3	^Citation17,Citation46,Citation54,Citation57
	Active learning	11	^Citation16,Citation18,Citation53,Citation55,Citation56,Citation58–63,Citation63,Citation65
	Not mentioned	1	^Citation11
Participant role	Learner	9	^Citation11,Citation17,Citation18,Citation46,Citation53–55,Citation57–59,Citation63
	Optometrist	6	^Citation16,Citation56,Citation60,Citation61,Citation63,Citation65
Pre-briefing	Yes	5	^Citation18,Citation60,Citation61,Citation63,Citation65
	Not mentioned	11	^Citation11,Citation16,Citation17,Citation46,Citation53–59
Scenario	Yes	9	^Citation16,Citation17,Citation56,Citation58–61,Citation63,Citation65
	Not mentioned	7	^Citation11,Citation18,Citation46,Citation53–55,Citation57
De-briefing	Yes	5	^Citation16,Citation60,Citation61,Citation63,Citation65
	Not mentioned	11	^Citation11,Citation17,Citation18,Citation46,Citation53–59
Feedback	Yes	5	^Citation16,Citation56,Citation60,Citation61,Citation63,Citation65
	Not mentioned	11	^Citation11,Citation17,Citation18,Citation46,Citation53–55,Citation57–59
Evaluation	Yes	7	^Citation18,Citation53,Citation59–61,Citation63,Citation65
	Not mentioned	9	^Citation11,Citation16–18,Citation46,Citation54–58
Reflection	Yes	4	^Citation60,Citation61,Citation63,Citation65
	Not mentioned	12	^Citation11,Citation16–18,Citation46,Citation53–59

Furthermore, a separate investigation focused on deliberate practice and uncovered the affordances of the cognitive apprenticeship model.⁶¹ More recent work addresses the accessibility and inclusiveness of learning experiences drawing on the principles of Universal Design for Learning when considering how to incorporate virtual simulation.⁶⁵ Most studies incorporated XR as a mode for active learning within the curriculum (see Table 3).

Pedagogical approaches

In the reviewed literature, most studies implemented XR to refine technical skills for learners to use asynchronously, without the support of a pedagogical approach (see Table 3). A number of studies noted that due to the lack of resources on implementing XR in optometry education, it was challenging to introduce these learning activities into their curriculum in an evidence-based manner.^16,60 While there is no optometry-specific evidence, some studies drew on evidence from the wider HPE literature for implementing XR into the curriculum and using this four studies implemented the six phases of simulation (see Table 3).^61,61,63,65 One of these studies used XR for summative assessment within the curriculum.⁶⁰

The influence of XR on learning (RQ3)

The methodology and metrics used to evaluate the influence of XR on learning varied across studies. For example, learning outcomes were specifically referred to in fewer than half of the articles included in this literature review (Table 3).

Influence on training technical skills in optometry education

The influence on training technical skills with XR was evaluated by the performance of learners. Wei et al.⁵³ evaluated the satisfaction of learners to measure the acceptability and feasibility of using augmented reality in optometry education to train slit-lamp examination skills as well as the performance of learners using this prototype. Other studies compared the performance of learners on competency-based assessments after exposure to XR.

Two studies compared the influence of training refraction with the BHVI virtual refractor on the accuracy and efficiency of the performance of learners completing subjective refraction on patients in different cohorts.^11,18 However, a challenge in drawing conclusions from this work is that each study defined accuracy differently; one study determined accuracy using the competency standards defined by a tolerance set by the Optometry Council of Australian and New Zealand and compared the absolute difference between the subjective refraction results of learners and qualified optometrist,^11,18 whereas the other study determined accuracy of the performance of learners using the absolute difference to a qualified optometrist and autorefraction results.^11,18

Competency-based assessments were applied again in three studies that evaluated the influence of the Eyesi® Indirect Ophthalmoscope on developing the technical skills of learners. Two of these studies specifically compared the average scores of the performance of previous cohorts on competency-based assessments to that of a cohort that had learnt using XR.^55,58 The studies were performed at different institutions, with variations in their methodology; one study reported missing data and the results of these two studies conflicted, with one demonstrating no difference in performance of learners, whereas the other demonstrated a positive impact on performance of learners.

The third study compared competency-based assessment results from one cohort of learners to qualified optometrists for peer–peer or virtual reality training to quantify how many hours of deliberate practice are required to improve technical skills performing binocular indirect ophthalmoscopy.⁵⁹

The wide variation of methods applied to evaluate the influence of XR on training technical skills makes it difficult to draw comparisons. With conflicting findings and methodology, further investigations are needed to inform evidence-based teaching and learning in optometry education.

Influence on training non-technical skills in optometry education

In seminal literature on XR in optometry education, non-technical skills are partially investigated.^16,17 For example, one study incorporated virtual simulation to improve the clinical reasoning and communication skills of learners without specifically assessing these outcomes.⁶³ Another evaluated the influence of virtual simulation in training clinical reasoning by measuring self-perceived knowledge and academic ability finding that virtual simulation would not lead to improved self-assessment skills.⁵⁶ Doron et al. measured the influence of a virtual simulation learning activity on the development of reflective abilities of learners using the Groningen Reflection Ability Scale.⁶³ This showed a significant increase in reflective abilities of learners, however one limitation was the survey not being survey validated for the changes made to it for the study.

The influence of XR in optometry education on clinical reasoning, patient-centred care, evidence-based practice, communication and knowledge development was reported by a study showing that learners self-perceived improved development of these skills through virtual simulation.⁶⁰ A later study reported the perceptions of learners and educators of virtual simulation to develop of these skills using focus groups and the self-perceived improvement in diagnostic reasoning ability of learners post virtual simulation using the Diagnostic Thinking Inventory for Optometry.^61,62 Further phenomenological exploration provided insight to how virtual simulation could create inclusive learning environments using learner and educator perceptions as well as results from a Systems Usability Scale.^65,66

Future scope for XR in optometry education (RQ4)

The increased rate of publications relating to XR in optometry education between 2014 and 2023 is mirrored in other HPE disciplines.^13,73 In addition, as more learners begin to use XR outside the classroom and XR becomes more financially accessible, there may also be a further increase in the willingness of optometry educators to incorporate it into the curriculum.⁷³ This narrative review reveals a need to progress the discussion in optometry education to align the implementation and incorporation of XR in the curriculum. Thus, with optometry educators calling for research to guide this change in practice, there is work to be done.^16,60

In application

This review uncovered studies reporting on new ways of learning in optometry education and now the time has come to evaluate these to support the design of learning activities.⁷⁴ To promote better learning environments, educators need to address the persistent gaps in understanding how XR influences learning in optometry education. For instance, studies implementing XR for deliberate practice may have also benefitted from phases of simulation such as debriefing or feedback. While deliberate practice can give learners the opportunity to hone skills in simulation without the consistent feedback and debriefing their development can be stunted and lead to reinforced errors.³⁴ This may account for overconfidence described in training technical skills and subsequently positively impact the learning process.

The studies in this review mostly focused on the affordances of the educational technology. In optometry, technological innovations have transformed professional practice with validation and reliability studies to enhance evidence-based practice. As a result, implementation of XR in the curriculum has primarily adopted a technology-focused approach. However, educators must be aware that focusing on the capability of the technology, rather than the learning process, may impede the attainment of learning outcomes and sustainable impacts on learning.^75,76 This brings to light a long-standing contention with educational technology.^77,78

This review suggests that a subtle shift from a technology-focused approach towards a broader consideration of the pedagogy for designing, delivering and evaluating learning will have most value for learners. The following recommendations based on this narrative review in Table 4 call for changes in experimental and applied practice in optometry education to align with a more rigorous approach of teaching and learning. In doing so, optometry educators could add to the affordances that have been found in other HPE disciplines that incorporate XR into their curriculums.

Table 4. Recommendations for design elements when developing XR for optometry education.

Recommendation	Examples from literature	Suggestions for application in optometry education
Define the outcomes, such as learning objectives, relative to the intention of XR	Aligning the objectives of the virtual simulation to clinical and professionalism objectives.^Citation78	During a virtual reality experience that demonstrates the pathogenesis of macular degeneration learners quiz each other on defined terms and test knowledge of angiogenesis.
Promote active learning of participants	Supplementing lectures with virtual patient cases that are interactive and focus on particular learning points.^Citation79	Prior to a clinical skills tutorial on performing binocular vision assessments learners are provided the opportunity to trial their understanding of learning points on four virtual patients with binocular vision anomalies.
Take a learner-driven approach	Allow learners participating in a virtual patient simulation to self-prescribe and self-regulate peer-groups.^Citation80	Substitute a lecture on differentiating ‘red eye’ presentations with an activity for learners in their second year to separate and work through a virtual patient that has bacterial conjunctivitis, while facilitators circulate the room.
Orientate the activity with simulation-based pedagogy	Integrating staged debriefing into a clinical case scenario such as micro-debriefing.^Citation61,Citation81	For a group of first year students working though a virtually simulated clinical case scenario of a patient with diabetes to guide the narrative the facilitator provides debriefing at explicit decision-making points: differential diagnoses; history taking questions; clinical examinations; diagnosis; and management.^Citation61
Incorporate learning theories	Providing learners with an opportunity for deliberate practice to develop a technical skill.^Citation82	Learners are provided with the opportunity to refine their technical skills using the Eyesi® Indirect Ophthalmoscope with iterative formative feedback.

Many of the studies in this review focus on competency and/or use competency-based assessments to measure the outcomes of using XR. XR can also train learners to respond to dynamic environments in the workplace and provide evidence-based practice solutions grounded in patient-centred care.^83,84 By recognising the holistic role of XR in preparing future health professionals for complex tasks and dynamic contexts requiring agility, rather than solely for predefined acts in a linear fashion with outcome-based performances, educators can better prepare students for entry to the profession.^83,84 Such a shift can expand the role of XR into an integral part of the optometry curriculum, rather than an adjunct technology, used to replace experiential learning activities.¹

This work has commenced in optometry education in research that focused on developing non-technical skills, where XR drew out the learning journey, allowing learners to develop new knowledge through experience.^60,61 These experiences were also accessible due to the design of XR and underlying pedagogy.^60,61,65 Subsequent research could embed pedagogical approaches and extend on this to guide optometry educators with evidence for implementing XR into the curricula.

The technology to support implementing XR in optometry education is not lacking. Although the affordances experienced by other HPE have been underexplored in optometry education, XR might offer novel advantages not yet identified. For example, many clinical tasks during practical laboratories or placements in optometry education do not incorporate shared modelling that can be achieved with XR.

Limitations

The discussion in this narrative review is limited to studies published in English and to the context of optometry. This narrative review focused on educational research, studies that were undertaken in the training of ophthalmology were not included, though professionally optometry and ophthalmology share some skills, they exhibit distinct differences in the educational training.

Conclusion

The research on XR in optometry education is expanding. Current research is technology focused, mostly concerned with the description of the technology rather than the underlying pedagogical affordances XR offers the curriculum. In optometry education, there is limited understanding on how XR can be best used in teaching and learning practice and a need to evaluate technologies as well as developing evidence-based approaches to be maximally effective.

Future research should report on the adoption of learning theory and frameworks to provide more comprehensive research that will guide the future use of XR in optometry education. Optometric educators could look to the literature that speaks to virtual simulation more broadly in higher education; however, there may be something that optometry could uniquely offer to the conversation to opening the conceptual basis of XR and exploring it further in a different context – optometry education.

Acknowledgements

The authors would like to acknowledge Mr. Joseph Afonne for their insights in developing this narrative review.

Disclosure statement

No potential conflict of interest was reported by the author(s).