Digital learning tools and resources in ophthalmic surgery training: a narrative review

Introduction

With the advancements in technology and the development in the field of ophthalmic surgery, the training of ophthalmic surgeons needs to be supplemented by digital tools that offer enhanced precision training and adaptability. These new technological developments influence how surgeons learn and improve their skills. Traditional training methods, such as apprenticeships and wet lab simulations, could be supplemented by digital ophthalmic surgery training. The intricacy of ophthalmic surgery necessitates more precise and thorough training (1-4).

The shortage of skilled ophthalmic surgeons, particularly in low-income countries, highlights the need for increased surgical training (5). Traditional training methods face several challenges, including limited real-life surgical opportunities, a shortage of qualified trainers, and limited training resources (5,6). Advances in virtual reality (VR), artificial intelligence (AI), and simulation-based learning provide innovative ways to develop surgical skills (7). While novice trainees benefit most from low-fidelity simulators that teach fundamental skills, experienced trainees benefit more from high-fidelity simulators that offer task refinement, complex tissue interactions, and crisis scenario simulations, such as complication management (3,8).

Future ophthalmologists must be equipped for the evolving demands of their profession. It is advocated for teaching and learning methods that are modern, innovative, and collaborative. Advancements in surgical training technology present challenges, including high costs, the need for validation and standardisation, limited accessibility—particularly in middle- and low-income settings—and disparities in training quality across institutions. Integrating new technology into existing training programmes requires significant time and effort from educators and trainees (5).

Constructive alignment ensures that learning outcomes, assessment methods, teaching strategies, and content are integrated to enhance learning effectiveness (9). For training to be effective, methods and resources must be clearly outlined—this is where technology can play a key role in modern training programmes. However, technology should be viewed as a tool within the training process, not an add-on. It must be integrated seamlessly into the curriculum through thoughtful planning and structuring.

Despite rapid technological advances, the integration of digital tools such as VR, AI, and simulation-based learning into ophthalmic surgery training remains inconsistent, with persistent challenges of cost, accessibility, validation, and curriculum alignment—particularly in low-resource settings (10). A well-designed curriculum directly links its components to specific outcomes and should encompass the knowledge, skills and attitudes required from trainees. Integrating technology throughout the curriculum is essential to meet the needs of 21st-century learners (11). Additionally, longitudinal assessment – employing various assessment tools, including technology, is preferred to ensure trainees can be entrusted to practice competently.

The aim was to provide a synthesis of current literature on digital learning tools in ophthalmic surgery training by examining emerging technologies and trends, and their integration into educational programmes. This narrative review offers a structured framework for embedding digital tools into training programmes through constructive alignment, highlighting their potential to complement traditional methods, for different trainee levels, and promote more standardised, accessible, and effective ophthalmic surgery education. We present this article in accordance with the Narrative Review reporting checklist (available at https://aes.amegroups.com/article/view/10.21037/aes-25-29/rc).

Methods

To address the research objective, we conducted a qualitative synthesis of existing literature on digital learning tools and resources in ophthalmology surgery training. With the assistance of a librarian from the Library and Information Service at the University of the Free State, sources were identified using the following databases: EBSCOhost platform (Academic Search Ultimate, Africa-Wide Information, Applied Science & Technology Source Ultimate, CAB Abstracts with Full Text, CINAHL with Full Text, Communication & Mass Media Complete, Health Source, MEDLINE) and Scopus.

The search was limited to articles published from 2010 to February 2025. An example of the detailed search strategy of one database is available in the Appendix 1. The following keywords and Boolean operators were used to refine searches: ophthalmology surgical training; e-learning platforms and digital resources; mobile apps; online courses; VR; augmented reality (AR); AI; machine learning; collaborative and interactive platforms; simulators and high-fidelity models; trends and innovations.

All articles in English and with abstracts available, excluding non-empirical studies (e.g., editorials, commentaries), were included in the search. The articles were imported into Rayyan (Rayyan Systems Inc.; Cambridge, MA, USA), a web and mobile app for systematic reviews (12). The authors carried out independent, duplicate searches. All abstracts were reviewed, and potentially eligible articles were read in full. The final list of studies that met the eligibility criteria was compared, and disagreements were resolved through discussion. The search strategy is summarised in Table 1.

A total of 403 articles were reviewed, 10 duplicates were removed, and 172 articles were read to identify key themes. Findings across different studies were compared. All the authors critically assessed the quality and relevance of the sources.

Key content, findings and discussion

A stepwise approach to surgical training provides a structured framework for progressing skills from foundational knowledge to complex procedural expertise (11). Initially, trainees develop a solid understanding of the theoretical concepts and basic skills essential for surgery, forming the basis for further development. This is followed by engaging in procedural training, where they can practice the individual steps of various procedures and the entire procedure in a controlled environment. The final training phase involves team-based practice in authentic surgical settings, where trainees collaborate with other professionals, simulating real-life surgical conditions. This progression ensures that surgeons are proficient in technical skills and capable of working effectively within a surgical team, leading to optimal patient outcomes (13). In this process, various digital learning tools and resources can be employed to enhance ophthalmic surgery training.

Learning theories

Several learning theories can explain clinical and surgical training. Constructivism is a theory where knowledge is constructed by the individual learner through experiences (14). Learning is interactive, building on the student’s knowledge, facilitating its application to simulation-based and hands-on digital training. Kolb’s Experiential Learning Theory highlights the importance of learning through experience, reflection and active experimentation (15). Digital tools such as VR, AR and real-time feedback in surgical simulators foster hands-on practice, allowing learners to refine skills through reflection, formative assessment and progression to the next level.

Mastery learning theory emphasises the idea that all trainees can achieve a high level of understanding in a subject if given the necessary time and support, requiring them to master each concept before moving on to the next (16). The trainee’s competency gaps are identified and addressed through frequent assessments and feedback. Stepwise, mastery-based training ensures effective learning without overwhelming trainees by keeping them in the zone of proximal development (17). Digital platforms facilitate personalised learning and provide opportunities for repeated practice with feedback, ensuring learners achieve competency before performing real-life surgery.

Closely related to the mastery learning theory is Miller’s pyramid (18), which categorises clinical competence in educational settings and the workplace. This framework differentiates between knowledge at the lower levels and performance at the higher levels, offering a structured, progressive approach to learning in ophthalmic surgery training (18). It has been proven that simulated practice can effectively predict real-world clinical performance, supporting the adoption of performance-based assessments (19).

This review employed the principles represented by Miller’s pyramid as a framework to explore the application of digital tools and advancements in ophthalmic surgery training. Table 2 summarises the levels of Miller’s pyramid and the corresponding traditional and digital training tools relevant to ophthalmic surgery.

Knowledge and application of the knowledge in context

The way trainees learn has evolved significantly in the digital age. Rather than relying on textbooks and physical journals alone, they now prefer digital resources and e-learning platforms. Online courses, webinars, and virtual mentorship expand training opportunities, reducing the need for physical presence and supporting trainees in remote and international contexts (20,21). Emerging innovations in education include adaptive learning platforms and AI-powered digital tools with data analytics. These technologies personalise learning experiences based on individual trainees’ needs, progress, and abilities, ensuring a more efficient and tailored educational approach. AI-driven platforms continuously analyse learner performance, adjust content accordingly, and incorporate multimodal learning strategies to enhance retention and support individualised learning (22).

Several online learning platforms and online courses are already available to ophthalmology trainees. These include the American Academy of Ophthalmology (AAO) Education Portal (https://www.aao.org/education/education-browse), AAO Education app (https://play.google.com/store/apps/details?id=com.aao.cea.prod&hl=en_ZA), Cybersight by Orbis International (https://cybersight.org/), Eye Academy, a platform for comprehensive Fellow of the Royal College of Ophthalmology (FRCOphth) examination preparation (https://eye.academy/?gad_source=1&gclid=CjwKCAjwvr--BhB5EiwAd5YbXhfHTv3sT51-LE4xmw94VOo8-P1MNAkZRwHJGpa7FZ4nk8GiRtXgYBoC2uEQAvD_BwE), and Medscape Ophthalmology (https://www.medscape.org/ophthalmology. Video lectures and tutorials can be accessed on platforms such as Eyetube (https://eyetube.net/) and YouTube, featuring educational content from institutions such as the University College London (UCL) Eye Institute and the AAO. EyeWiki (by AAO) is a knowledge-sharing platform for collaborative and interactive learning where trainees and experts contribute and access up-to-date ophthalmology content (https://eyewiki.org/Main_Page).

Microlearning, an online format that delivers concise, easily accessible information units, allows professionals to acquire knowledge efficiently without real-time or interpersonal interaction (20). Microlearning involves participation in learning activities composed of loosely connected microcontent (23). Just-in-time teaching (JiTT) is an effective instructional method that seamlessly integrates into daily clinical teaching, enabling both trainees and faculty to use it efficiently in a fast-paced clinical setting. Delivery systems for JiTT include learning management systems, mobile apps and social media platforms (23). Ensuring accessibility in lower-resource settings is essential, and the widespread availability of mobile phones provides a practical means of delivering training and educational resources.

Digital learning methods, including software, videos, gaming, online classes, and augmented and VR, offer many advantages in enhancing trainees’ knowledge and skills. These methods transcend time and location constraints, allowing students to learn and practice repeatedly, anytime and anywhere (24). Three-dimensional (3D) technology enables the development of intricate, interactive anatomical models that offer a more lifelike depiction of the human body than conventional two-dimensional (2D) images or diagrams to improve visualisation and comprehension of anatomical structures and better depth perception (25). Trainees gain significant value from prior learning and guidance from experienced instructors before training on VR simulators (26). Remote learning is an effective educational modality providing learners with standardised training and equal opportunities (22).

Advantages of digital tools include improved knowledge acquisition and creating a more inclusive and globally connected ophthalmology education system (27). Additionally, trainees can review surgical techniques at their own pace, reinforcing learning and skills development (28). Remote supervision by experienced surgeons ensures guidance and oversight, enhancing the overall training experience (29). Furthermore, 3D live streaming could transform ophthalmology education by eliminating traditional in-person surgical observation’s geographic and physical limitations. Integrating metaverse and Web3 technologies offers innovative platforms for sharing knowledge, potentially enhancing how we perform surgeries, teach, learn, and transfer information (30).

Technology-enhanced learning has grown in popularity but presents several challenges and limitations. Human factors such as motivation, self-discipline, limited interaction, time management struggles, lack of personalised guidance, and screen fatigue can impact learning effectiveness. Additionally, technical issues such as unstable internet connections, inadequate devices and software problems further restrict accessibility (24).

Trainee learning has undergone a substantial transformation in the digital era, consistent with the World Economic Forum’s Schools of the Future report, which outlines core competencies required for education in the Fourth Industrial Revolution (4IR). These include global citizenship, innovation and creativity, technological competence, and interpersonal skills (31). In ophthalmology, surgical training increasingly integrates traditional methodologies with modern innovations (25).

Digital tools in the assessment of knowledge acquisition

Assessment in surgical training should be carefully planned and integrated into the training programme using the principles of constructive alignment (9). This approach ensures that learning outcomes, assessment methods, teaching strategies and content are aligned to enhance learning effectiveness. Various digital platforms support knowledge assessment of surgical training through diverse assessment methods, including:

• Multiple-choice question platforms: these platforms offer quizzes to test foundational medical knowledge, reinforcing key concepts.
• Interactive e-learning courses: these courses deliver theoretical knowledge on medical subjects and incorporate self-assessment exercises to evaluate understanding.
• Digital simulation scenarios: these virtual environments allow trainees to apply their knowledge to diagnose and develop treatment plans for simulated patients, fostering clinical decision-making skills.
• Case-based learning platforms: these online systems present clinical cases, encouraging the application of theoretical knowledge to real-world clinical situations.

Integrating these digital tools within a constructively aligned framework can enhance the assessment process, providing comprehensive and practical evaluation methods throughout the ophthalmology training programme. These tools can be used for formative assessment with immediate digital feedback for assessment for learning or for summative assessment of learning to make judgments regarding a trainee’s competence or fitness to practice (32).

Technology to enhance performance training

According to Lansingh and Nair (26), trainees benefit greatly from prior knowledge and the mentorship of experienced instructors before engaging in simulation-based training. After this initial phase, they engage in procedural training, allowing them to practice individual steps and procedures in a controlled setting. Access to wet lab and simulator environments is facilitated by integrating a structured surgical training curriculum into residency programmes. Wet lab and simulator training shorten the learning curve for novice surgeons, helping them to develop tissue awareness, dexterity and psychomotor skills needed to perform each procedure step safely (3). Simulator training can be incorporated before the live patient experience or integrated alongside learner presence in the operating room. Team-based practice in realistic surgical environments, where trainees work alongside other professionals to simulate actual surgical conditions, addresses behavioural skills.

Integrating a comprehensive surgical training curriculum into residency programmes requires access to wet labs and simulator environments. The transfer of surgical skills from experienced surgeons to resident surgeons is complex, as the teaching surgeon typically assumes the role of an observer rather than directly performing the procedure. To address this challenge and accelerate the learning curve for novice surgeons, wet lab and simulator training is employed, providing hands-on practice in a controlled environment (3,33). Several categories of simulation models are used for training and assessment, including animal and cadaver models, and inanimate and VR models (10). Advances in technology and the continuous development of new simulators have led to state-of-the-art models focusing on various surgical procedures and integrating all the steps to complete a procedure. In cataract surgery, three well-described approaches are used to teach individual steps, namely forward, backward, and deconstructed step-by-step instruction (3), and these approaches can be incorporated into simulator-based training.

VR technology offers surgical step training, scenario simulations and immersive evaluation exams (7). Thomsen et al. (34) found a high correlation between the performance of a VR simulator (EyeSi simulator; Haag-Streit Group; Köniz, Switzerland) and real-life cataract surgery. There are options to guide trainees in managing difficult and complicated cases, such as grooving a cataractous lens with an ultrasound probe during the phacosculpting procedure in a simulated environment (35). The benefits of VR simulation are that it allows for understanding preoperative anatomy, surgical positioning and basic microscopic operations, resulting in reducing surgical risks (7).

The urgent need to train surgeons quickly and comprehensively in high-quality, low-cost cataract removal techniques is growing. Singh and Strauss (36) advocated for manual small-incision cataract surgery (MSICS) as a safe, effective and affordable alternative to phacoemulsification (PE), particularly in developing countries. They presented a novel, full-immersion, physics-based surgical training simulator as the cornerstone of a scalable and comprehensive MSICS training system (36). A study comparing PE and MSICS in a simulation environment suggested a positive transfer of skills between the two procedures. The findings indicated that prior PE experience offers an advantage when undertaking MSICS training in surgical residency programmes (37).

Combining VR simulation with wet lab phacoemulsification training could effectively transfer surgical skills to the operating theatre. The impact of VR training for cataract surgery on the operating performance of postgraduate ophthalmology trainees was reviewed by Lin et al. (38), who conducted a Cochrane review that evaluated operating time, intraoperative complications, postoperative complications, supervising physician ratings, and VR simulator task performance. Emerging evidence suggests that VR training may enhance the performance of trainees in both simulated environments and the operating room compared with no additional training, although the certainty of this evidence is limited. Comparisons of VR training with conventional or wet-lab approaches, however, have produced less consistent results (34,38).

Apart from cataract simulators, several other procedural simulators are available, such as vitreoretinal training, retrobulbar blocks using an ophthalmic anaesthesia simulation system, orbital models, and models of intraocular tumours using 3D printers (3).

VR retina surgery simulators capable of integrating optical coherence tomography (OCT) scans from actual patients can be used for practicing vitreoretinal surgery using different pathologic scenarios (39). Using vitreoretinal surgical training tools can complement hands-on experience for vitreoretinal surgical fellows. Simulators and standardised rubrics may help streamline training, facilitate the achievement of surgical milestones, and provide reliable feedback to enhance surgical competency and improve patient outcomes (40).

A new virtual surgery software-computed simulation platform (Kc_mean) was developed to predict postoperative corneal mechanical rigidity following laser vision correction (LVC) surgery. This user-friendly software enables clinicians to simulate post-LVC corneal stiffness and has been evaluated in post-small incision lenticule extraction (SMILE) ectasia cases. Further assessments of eyes with postsurgical ectasia are needed (41).

An improved surgical eye model for simulating glaucoma procedures features a scleral model mimicking the human sclera in biomechanical and morphological characteristics. Using electrospinning technology, the authors successfully engineered a multilayer scleral model with an elasticity of 13 MPa, replicating the structure of the human sclera. This model is suitable for training medical professionals and evaluating medical equipment used in glaucoma surgeries (42). The technology was used to engineer this model, but the model is not technologically advanced.

When comparing the cost-effectiveness of these training methods, the VR simulator—despite its high initial capital cost—offers greater long-term cost efficiency due to its relatively low recurring expenses (43). The literature highlights a wide range of technologically advanced training tools for various procedures in ophthalmic surgery. Integrating these tools into training programmes should be constructively aligned with learning objectives and assessment methods. There is a notable gap in the literature regarding the long-term (1–5 years) impact of digital training on surgeon skills retention and patient outcomes. While several studies confirm that simulation-based training improves skills acquisition, confidence, and short-term performance, high-quality, longitudinal research on sustained effects remains limited (34,38,44).

Digital tools in performance assessment in ophthalmic surgery training

Performance assessments of trainees and practicing ophthalmologists focus on performance indicators, simulation and workplace-based assessment (WBA) (45). Integrating digital assessment tools aligned with Miller’s pyramid ensures a thorough evaluation of ophthalmology trainees, from foundational knowledge to real-world clinical performance. Thomsen et al. (34) recommended using multiple data sources, such as objective structured clinical examinations (OSCEs) via virtual platforms, where trainees perform specific tasks in simulated environments while being assessed remotely, or simulation-based assessments using high-fidelity simulators to evaluate and provide feedback on procedural skills in a controlled, virtual setting.

Various surgical assessment tools include procedure-related checklists, global rating scales, simulated assessments (wet lab, dry lab or virtual), knowledge-based outcomes and motion analysis. It is important to evaluate whether these assessment tools have been validated properly and provide reliable and appropriate feedback to trainees, and if they are reliable to test the threshold of competency (46).

Performance assessment in real-world settings includes e-portfolios, which use digital collections of real clinical experiences, reflective entries, and feedback to showcase actual performance. Workplace-based assessments (WBAs) with digital documentation allow supervisors to record and evaluate trainees’ performance during clinical practice (45).

Tools for assessing competency-based instruction in ophthalmic surgery include the Objective Assessment of Skills in Intraocular Surgery (OASIS), complemented by the Global Rating Assessment of Skills in Intraocular Surgery (GRASIS), which evaluates non-technical skills. The combination of these tools provides a comprehensive, holistic assessment of a trainee’s capabilities in intraocular surgery. The International Council of Ophthalmology’s Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR) are standardised, internationally validated tools developed by the International Council of Ophthalmology to teach and assess an ophthalmologist’s competence in performing various surgeries. The rubrics provide specific behavioural descriptions for each step of a procedure, facilitating structured feedback and targeted improvement (3). These competency assessment tools for ophthalmic surgery are available in digital formats, facilitating their integration into modern training and evaluation systems. These tools should be practical to implement and designed to encourage learner engagement. An integrated, multi-source approach improves the accuracy and validity of performance assessments in ophthalmology training.

A holistic approach fosters more effective, authentic and learner-centred assessment practices. Harden and Lilley (32) proposed emerging trends in assessment through the Assessment PROFILE framework, which is summarised with applications in ophthalmology training in Table 3.

New directions in surgical skills assessment may include incorporating AI and deep learning algorithms, portable simulation solutions and advanced haptic feedback to improve precision and sensitivity (49). Future research and development should incorporate new technology for automated, real-time, objective surgical feedback and competency tracking (46). Cloud-based simulation platforms will empower education programmes to offer accessible, adaptable and collaborative learning experiences, enhancing real-time interaction.

Limitations

As a narrative review, this study is limited by the absence of a systematic search strategy and formal quality appraisal, which could introduce selection bias and reduce reproducibility. The depth of analysis may vary across topics, and some relevant studies might have been overlooked. Consequently, the findings reflect a broad synthesis of existing literature rather than a comprehensive or fully representative body of evidence; therefore, it should be interpreted with appropriate caution. However, from the nature of a narrative review, the flexible approach allows for integration of diverse perspectives and identification of gaps, offering a structured framework for incorporating digital tools that can inform educators, policymakers, and researchers.

Conclusions

The integration of digital technologies into ophthalmic surgical training offers significant potential to enhance educational efficiency, standardisation, and accessibility. Tools such as VR, AR, and AI provide risk-free environments for skills acquisition, objective performance evaluation, and personalised feedback, while telemedicine and remote learning expand opportunities for global collaboration and mentorship. Although challenges remain—including high costs, disparities in access, and the need for validation and standardisation—strategic solutions such as shared simulation centres, government and private sector funding, and international partnerships can mitigate these barriers.

Ultimately, the integration of digital innovations into ophthalmic surgery education must be guided by rigorous evaluation of their educational impact, cost-effectiveness, and scalability across diverse contexts. Collaboration between educators, clinicians, technologists, and policymakers will be critical to developing adaptable training models that balance technological advancement with equitable access.

In conclusion, while barriers remain, the thoughtful and strategic incorporation of VR, AR, AI, and other digital tools into ophthalmic surgery training holds the potential to revolutionise education. By fostering standardised, accessible, and competency-based learning, these innovations will not only enhance the skills of future surgeons but also ultimately improve the quality and safety of patient care worldwide.

Acknowledgments

We thank Ms. Annamarie du Preez, assistant director, Frik Scott Library, Faculty of Health Sciences, University of the Free State, for assistance with the literature search; and Dr. Daleen Struwig, medical writer/editor, Faculty of Health Sciences, University of the Free State, for technical and editorial preparation of the article.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Eye Science for the series “Optimizing Ophthalmology Surgery Training Through Active Learning Strategies”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aes.amegroups.com/article/view/10.21037/aes-25-29/rc

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-25-29/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-25-29/coif). The series “Optimizing Ophthalmology Surgery Training Through Active Learning Strategies” was commissioned by the editorial office without any funding or sponsorship. H.P.F. serves as an unpaid editorial board member of Annals of Eye Science from October 2024 to December 2026. M.J.L. and H.P.F. served as the unpaid Guest Editors of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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