Ophthalmology residency surgical training and competency assessment: a systematic review of medical education evidence

Surgical competency in ophthalmology residency training is influenced by multiple factors, including cumulative case volume, supervisory experience, and access to simulation-based education. However, the evidence base evaluating these factors remains fragmented across heterogeneous study designs and outcome measures. To synthesize the available medical education evidence on ophthalmology surgical training and assessment of surgical competence among residents and trainee ophthalmologists, while mapping outcome domains and characterizing the direction and magnitude of reported effects. A systematic review was conducted in accordance with the PRISMA 2020 guidelines. Four electronic databases (PubMed, Scopus, the Cochrane Library, and ERIC) were searched [December 2025]. Studies were eligible if they evaluated surgical training outcomes among ophthalmology residents, including intraoperative or postoperative complications, surgical efficiency, case-volume/learning-curve effects, surgical success, trainee competency, or the impact of simulation-based training. Non-residency populations and studies evaluating non-surgical educational interventions were excluded. Two reviewers independently screened titles/abstracts and full texts, with discrepancies resolved by consensus. Risk of bias was assessed using design-specific tools: the Joanna Briggs Institute (JBI) critical appraisal checklists for observational studies, the Cochrane Risk of Bias 2 (RoB 2) tool for randomized controlled trials, and the COSMIN Risk of Bias checklist for the instrument validation study. Given substantial heterogeneity in populations, interventions, and outcome measures, findings were synthesized narratively rather than through meta-analysis. Of 4,233 records identified, 12 studies published between 2007 and 2022 met the inclusion criteria, conducted in the United States, United Kingdom, India, Australia, and sub-Saharan Africa. Case volume was consistently associated with reduced complication rates, though case-specific risk factors also independently predicted complications. Trainee-performed surgery was associated with higher short-term complication rates than surgery performed by experienced surgeons, though long-term outcomes were often comparable. Simulation-based and virtual-reality training was consistently associated with lower complication rates and higher competence scores across four studies, including two randomized controlled trials. Validated competency assessment instruments remain limited, with only one study addressing instrument validity in depth. Simulation-based training and structured, experience-matched case selection are associated with improved surgical outcomes and surgical competence among ophthalmology residents. However, the evidence base is concentrated in high-income countries and relies predominantly on observational designs, highlighting the need for more geographically diverse, prospective research and validated assessment tools, particularly for cataract surgery.