BackgroundThis study aims to assess the quality of various steps of manual small incision cataract surgery and predictors of quality, using video recordings. DesignThis paper applies a retrospective study. ParticipantsFifty-two trainees participated in a hands-on small incision cataract surgery training programme at rural Chinese hospitals. MethodsTrainees provided one video each recorded by a tripod-mounted digital recorder after completing a one-week theoretical course and hands-on training monitored by expert trainers. Videos were graded by two different experts, using a 4-point scale developed by the International Council of Ophthalmology for each of 12 surgical steps and six global factors. Grades ranged from 2 (worst) to 5 (best), with a score of 0 if the step was performed by trainers. Main Outcome MeasuresMean score for the performance of each cataract surgical step rated by trainers. ResultsVideos and data were available for 49/52 trainees (94.2%, median age 38 years, 16.3% women and 77.5% completing>50 training cases). The majority (53.1%, 26/49) had performed50 cataract surgeries prior to training. Kappa was 0.57 approximate to 0.98 for the steps (mean 0.85). Poorest-rated steps were draping the surgical field (meanstandard deviation=3.27 +/- 0.78), hydro-dissection (3.88 +/- 1.22) and wound closure (3.92 +/- 1.03), and top-rated steps were insertion of viscoelastic (4.96 +/- 0.20) and anterior chamber entry (4.69 +/- 0.74). In linear regression models, higher total score was associated with younger age (P=0.015) and having performed >50 independent manual small incision cases (P=0.039). ConclusionsMore training should be given to preoperative draping, which is poorly performed and crucial in preventing infection. Surgical experience improves ratings.