Cost-effectiveness of virtual reality and wet laboratory cataract surgery simulation.

PURPOSE: To evaluate the cost-effectiveness of phacoemulsification simulation training in virtual reality simulator and wet laboratory on operating theater performance. METHODS: Residents were randomized to a combination of virtual reality and wet laboratory phacoemulsification or wet laboratory phacoemulsification. A reference control group consisted of trainees who had wet laboratory training without phacoemulsification. All trainees were assessed on operating theater performance in 3 sequential cataract patients. International Council of Ophthalmology Surgical Competency Assessment Rubric-phacoemulsification (ICO OSCAR phaco) scores by 2 masked independent graders and cost data were used to determine the incremental cost-effectiveness ratio (ICER). A decision model was constructed to indicate the most cost-effective simulation training strategy based on the willingness to pay (WTP) per ICO OSCAR phaco score gained. RESULTS: Twenty-two trainees who performed phacoemulsification in 66 patients were analyzed. Trainees who had additional virtual reality simulation achieved higher mean ICO OSCAR phaco scores compared with trainees who had wet laboratory phacoemulsification and control (49.5 ± standard deviation [SD] 9.8 vs 39.0 ± 15.8 vs 32.5 ± 12.1, P < .001). Compared with the control group, ICER per ICO OSCAR phaco of wet laboratory phacoemulsification was $13,473 for capital cost and $2209 for recurring cost. Compared with wet laboratory phacoemulsification, ICER per ICO OSCAR phaco of additional virtual reality simulator training was US $23,778 for capital cost and $1879 for recurring cost. The threshold WTP values per ICO OSCAR phaco score for combined virtual reality simulator and wet laboratory phacoemulsification to be most cost-effective was $22,500 for capital cost and $1850 for recurring cost. CONCLUSIONS: Combining virtual reality simulator with wet laboratory phacoemulsification training is effective for skills transfer in the operating theater. Despite of the high capital cost of virtual reality simulator, its relatively low recurring cost is more favorable toward cost-effectiveness.

Using the language of surgery to enhance ophthalmology surgical education.

Background: Currently, surgical education utilizes a combination of the apprentice model, wet-lab training, and simulation, but due to reliance on subjective data, the quality of teaching and assessment can be variable. The "language of surgery," an established concept in engineering literature whose incorporation into surgical education has been limited, is defined as the description of each surgical maneuver using quantifiable metrics. This concept is different from the traditional notion of surgical language, generally thought of as the qualitative definitions and terminology used by surgeons. Methods: A literature search was conducted through April 2023 using MEDLINE/PubMed using search terms to investigate wet-lab, virtual simulators, and robotics in ophthalmology, along with the language of surgery and surgical education. Articles published before 2005 were mostly excluded, although a few were included on a case-by-case basis. Results: Surgical maneuvers can be quantified by leveraging technological advances in virtual simulators, video recordings, and surgical robots to create a language of surgery. By measuring and describing maneuver metrics, the learning surgeon can adjust surgical movements in an appropriately graded fashion that is based on objective and standardized data. The main contribution is outlining a structured education framework that details how surgical education could be improved by incorporating the language of surgery, using ophthalmology surgical education as an example. Conclusion: By describing each surgical maneuver in quantifiable, objective, and standardized terminology, a language of surgery can be created that can be used to learn, teach, and assess surgical technical skill with an approach that minimizes bias. Key message: The "language of surgery," defined as the quantification of each surgical movement's characteristics, is an established concept in the engineering literature. Using ophthalmology surgical education as an example, we describe a structured education framework based on the language of surgery to improve surgical education. Classifications: Surgical education, robotic surgery, ophthalmology, education standardization, computerized assessment, simulations in teaching. Competencies: Practice-Based Learning and Improvement.

Distinguishing Glaucoma, Cataract, and Glaucoma Suspect Based on Visual Symptoms.

PRCIS: Cataract, glaucoma, and glaucoma suspect patients report differing visual symptoms. Asking patients about their visual symptoms may provide useful diagnostic information and inform decision-making in patients with comorbid conditions. PURPOSE: To compare visual symptoms in glaucoma, glaucoma suspect (controls), and cataract patients. METHODS: Glaucoma, cataract, and glaucoma suspect patients at Wilmer Eye Institute responded to a questionnaire rating the frequency and severity of 28 symptoms. Univariate and multivariable logistic regression determined the symptoms that best differentiate each disease pair. RESULTS: In all, 257 patients (mean age: 67.4 ± 13.4 y; 57.2% female; 41.2% employed), including 79 glaucoma, 84 cataract, and 94 glaucoma suspect patients, participated. Compared with glaucoma suspects, glaucoma patients were more likely to report poor peripheral vision (OR 11.29, 95% CI: 3.73-34.16), better vision in 1 eye (OR 5.48, 95% CI: 1.33-22.64), and light sensitivity (OR 4.85, 95% CI: 1.78-13.24), explaining 40% of the variance in diagnosis (ie, glaucoma vs. glaucoma suspect). Compared with controls, cataract patients were more likely to report light sensitivity (OR 3.33, 95% CI: 1.56-7.10) and worsening vision (OR 12.20, 95% CI: 5.33-27.89), explaining 26% of the variance in diagnosis (ie, cataract vs. glaucoma suspect). Compared with cataract patients, glaucoma patients were more likely to report poor peripheral vision (OR 7.24, 95% CI: 2.53-20.72) and missing patches (OR 4.91, 95% CI: 1.52-15.84), but less likely to report worsening vision (OR 0.08, 95% CI 0.03-0.22), explaining 33% of the variance in diagnosis (ie, glaucoma vs. cataract). CONCLUSIONS: Visual symptoms distinguish disease state to a moderate degree in glaucoma, cataract, and glaucoma suspect patients. Asking about visual symptoms may serve as a useful diagnostic adjunct and inform decision-making, for example, in glaucoma patients considering cataract surgery.

Opportunity Cost to Attending Surgeons of Intraoperative Training for Residents in Cataract Surgery.

Purpose: To estimate the opportunity cost to attending surgeons of teaching residents cataract surgery in the operating room. Patients and methods: Operating room records at an academic teaching hospital from July 2016 to July 2020 were analyzed in this retrospective review of cases. Cases were identified using Current Procedural Terminology (CPT) codes 66982 and 66984 for cataract surgery. Outcomes measured include operative time and work relative value units (wRVUs). Cost analysis was performed using the generic 2021 Medicare Conversion Factor. Results: Of 8813 cases, 2906 (33.0%) included resident involvement. For CPT 66982 cases, median (interquartile range (IQR)) operative time was 47 (22) minutes with resident involvement and 28 (18) minutes without (p<0.001). For CPT 66984 cases, median (IQR) operative time was 34 (15) minutes with resident involvement and 20 (11) minutes without (p<0.001). Median wRVUs was 78.5 (20.9) with resident involvement and 61.0 (14.4) without (p<0.001) which converted to an opportunity cost (IQR) per case of $1393.72 ($1055.63). Among cases involving residents, median operative time was significantly higher during the first and second quarters (p<0.001) and for every quarter when compared to cases performed by attendings only (p<0.001). Conclusion: Teaching cataract surgery in the operating room is associated with a considerable opportunity cost for attending surgeons.

Assessing Resident Cataract Surgical Outcomes Using Electronic Health Record Data.

Objective: To demonstrate that electronic health record (EHR) data can be used in an automated approach to evaluate cataract surgery outcomes. Design: Retrospective analysis. Subjects: Resident and faculty surgeons. Methods: Electronic health record data were collected from cataract surgeries performed at the Johns Hopkins Wilmer Eye Institute, and cases were categorized into resident or attending as primary surgeon. Preoperative and postoperative visual acuity (VA) and unplanned return to operating room were extracted from the EHR. Main Outcome Measures: Postoperative VA and reoperation rate within 90 days. Results: This study analyzed 14 537 cataract surgery cases over 32 months. Data were extracted from the EHR using an automated approach to assess surgical outcomes for resident and attending surgeons. Of 337 resident surgeries with both preoperative and postoperative VA data, 248 cases (74%) had better postoperative VA, and 170 cases (51%) had more than 2 lines improvement. There was no statistical difference in the proportion of cases with better postoperative VA or more than 2 lines improvement between resident and attending cases. Attending surgeons had a statistically greater proportion of cases with postoperative VA better than 20/40, but this finding has to be considered in the context that, on average, resident cases started out with poorer baseline VA.A multivariable regression model of VA outcomes vs. resident/attending status that controlled for preoperative VA, patient age, American Society of Anesthesiologists (ASA) score, and estimated income found that resident status, preoperative VA, patient age, ASA score, and estimated income were all significant predictors of VA. The rate of unplanned return to the operating room within 90 days of cataract surgery was not statistically different between resident (1.8%) and attending (1.2%) surgeons. Conclusions: This study demonstrates that EHR data can be used to evaluate and monitor surgical outcomes in an ongoing way. Analysis of EHR-extracted cataract outcome data showed that preoperative VA, ASA classification, and attending/resident status were important in predicting postoperative VA outcomes. These findings suggest that the utilization of EHR data could enable continuous assessment of surgical outcomes and inform interventions to improve resident training. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Implementation and Evaluation of Integrating an Electronic Health Record With the ACGME Case Log System.

Background: It is essential to log resident-performed procedures to assess training programs and fulfill specialty requirements, but resident case numbers are often underreported. Current systems require inefficient data entry steps, and residents and fellows report that user interfaces and administrative burden contribute to logging inaccuracy. Objective: To determine the accuracy, feasibility, and acceptability of a single logging approach for resident case logging. Methods: In 2018, we implemented a case logging system integrated with the institutional electronic health record (EHR) and the Accreditation Council for Graduate Medical Education (ACGME) case log system to record procedures performed by ophthalmology residents. We compared the proportion of resident-performed cataract extractions in the EHR that were reported to ACGME for 3 periods: before the deployment of the new system (6 months), during the transition (6 months), and after the change (2 years). Resident satisfaction with the new system was evaluated using surveys. Results: An analysis of resident cataract surgeries showed that the percentage of resident cases logged increased from 85% prior to implementation to 91% after implementation. The integrated system became the preferred case logging method, with 100% of all logged cases being entered using the new platform. Surveys showed that the percentage of trainees who were moderately or very satisfied with the case log process increased from 55% before implementation to 100% after implementation. Conclusions: A resident case log system integrated with an EHR more accurately reflects resident operative volume and increases trainee satisfaction with the logging process.

Video-based assessment of intraoperative surgical skill.

PURPOSE: Surgeons' skill in the operating room is a major determinant of patient outcomes. Assessment of surgeons' skill is necessary to improve patient outcomes and quality of care through surgical training and coaching. Methods for video-based assessment of surgical skill can provide objective and efficient tools for surgeons. Our work introduces a new method based on attention mechanisms and provides a comprehensive comparative analysis of state-of-the-art methods for video-based assessment of surgical skill in the operating room. METHODS: Using a dataset of 99 videos of capsulorhexis, a critical step in cataract surgery, we evaluated image feature-based methods and two deep learning methods to assess skill using RGB videos. In the first method, we predict instrument tips as keypoints and predict surgical skill using temporal convolutional neural networks. In the second method, we propose a frame-wise encoder (2D convolutional neural network) followed by a temporal model (recurrent neural network), both of which are augmented by visual attention mechanisms. We computed the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and predictive values through fivefold cross-validation. RESULTS: To classify a binary skill label (expert vs. novice), the range of AUC estimates was 0.49 (95% confidence interval; CI = 0.37 to 0.60) to 0.76 (95% CI = 0.66 to 0.85) for image feature-based methods. The sensitivity and specificity were consistently high for none of the methods. For the deep learning methods, the AUC was 0.79 (95% CI = 0.70 to 0.88) using keypoints alone, 0.78 (95% CI = 0.69 to 0.88) and 0.75 (95% CI = 0.65 to 0.85) with and without attention mechanisms, respectively. CONCLUSION: Deep learning methods are necessary for video-based assessment of surgical skill in the operating room. Attention mechanisms improved discrimination ability of the network. Our findings should be evaluated for external validity in other datasets.

Addressing the MSICS learning curve: identification of instrument-holding techniques used by experienced surgeons.

AIM: To identify instrument holding archetypes used by experienced surgeons in order to develop a universal language and set of validated techniques that can be utilized in manual small incision cataract surgery (MSICS) curricula. METHODS: Experienced cataract surgeons performed five MSICS steps (scleral incision, scleral tunnel, side port, corneal tunnel, and capsulorhexis) in a wet lab to record surgeon hand positions. Images and videos were taken during each step to identify validated hand position archetypes. RESULTS: For each MSICS step, one or two major archetypes and key modifying variables were observed, including tripod for scleral incision, tripod-thumb bottom for scleral tunnel, underhand-index to thumb grip for side port, index-contact tripod for corneal entry, and tripod-forceps for capsulorhexis. Key differences were noted in thumb placement and number of fingers supporting the instrument, and modifying variables included index finger curvature and amount of flexion. CONCLUSION: Identification of optimal hand positions and development of a formal nomenclature has the potential to help trainees adopt hand positions in an informed manner, influence instrument design, and improve surgical outcomes.

Current methods for assessing technical skill in cataract surgery.

Surgery is a major source of errors in patient care. Preventing complications from surgical errors in the operating room is estimated to lead to reduction of up to 41 846 readmissions and save $620.3 million per year. It is now established that poor technical skill is associated with an increased risk of severe adverse events postoperatively and traditional models to train surgeons are being challenged by rapid advances in technology, an intensified patient-safety culture, and a need for value-driven health systems. This review discusses the current methods available for evaluating technical skills in cataract surgery and the recent technological advancements that have enabled capture and analysis of large amounts of complex surgical data for more automated objective skills assessment.

What are Ophthalmology Patients Asking Online? An Analysis of the Eye Triage Subreddit.

IMPORTANCE: Ophthalmology patients are seeking medical advice on social media websites like Reddit, where users are able to post comments and discuss issues pertaining to different topics that are organized in 'subreddits'. Understanding which issues are most pertinent will guide ophthalmic providers in delivering more effective patient education. METHODS: This cross-sectional study assessed a systematic sample of the first 22 posts and their top 3 comments from each month since January 27th, 2019, the subreddit's creation. Information was gathered from reddit.com/r/eyetriage in October 2019 and analyzed in November 2019. MAIN OUTCOMES: The posts were characterized by date and time, inclusion of an image, type, content, emotional tone, and number of upvotes and comments. The comments were categorized based on content, emotional tone, time of comment, and user background. Post and comment content codes were categorized in an iterative manner with differences resolved by author consensus. Categorical statistics were compiled. RESULTS: Two hundred posts and 456 comments were analyzed since the creation of r/eyetriage, a forum created exclusively for patients to seek advice from health-care professionals. Twenty-six (13%) of the total posts included an image. On average, comments received 1.76 ± 2.17 upvotes along with 4.50 ± 4.47 replies. The most common content codes among the posts were 42 (21.0%) seeking diagnoses, 23 (11.5%) surgical complications, and 13 (6.50%) alternative medication options. Eighty-two (41%) posts conveyed a clear emotional tone, most notably 11 (13.4%) with anxiety and 10 (12.2%) with worry. The top comments came from 165 (36.2%) self-identified patients, 151 (33.1%) optometrists, and 49 (10.8%) ophthalmologists. The top comment codes for replies included 158 (34.7%) with treatment advice, 70 (15.4%) with advice deferred to follow-up appointment with other health-care specialists, and 60 (13.2%) with sharing information. CONCLUSIONS: Patients are asking ophthalmology-related questions on the Eye Triage subreddit, and they are more likely to receive information from other patients or optometrists than from self-identified ophthalmologists. When emotions were revealed, patients were often anxious and worried. Opportunities exist for ophthalmologists to take a more active role on this subreddit and help educate patients.

Objective assessment of technical skill targeted to time in cataract surgery.

PURPOSE: To evaluate time as an objective measure of technical skill assessment in cataract surgery. SETTING: Single academic center. DESIGN: Cross-sectional study. METHODS: One hundred videos of cataract surgery (29 performed by a faculty and 71 performed by trainee surgeons) performed at the Wilmer Eye Institute between July 2011 and December 2017 were analyzed for surgical technical skill as a function of time using task-specific indices, global skill indices, and appointment status. RESULTS: Expert surgeons, defined by global skill, did not consistently have shorter times to complete phases in cataract surgery compared with novice surgeons. Time to complete phases in cataract surgery was predictive of global skill (area under the curve [AUC] of 0.73, 95% CI: 0.63-0.83) and of surgeons' appointment status (AUC 0.82, 95% CI: 0.70-0.91). Time for capsulorhexis correctly distinguished between expert-novice skill class only 58% (AUC 0.58, 95% CI: 0.47-0.69) of the times when capsulorhexis indices were used and 51% (AUC 0.51, 95% CI: 0.39-0.63) of the times when global indices were used. Time to complete quadrants in capsulorhexis also had a low ability to discriminate between novice and expert instances for capsulorhexis skill and global skill. The AUC was 0.54 (95% CI: 0.44-0.66) and 0.53 (95% CI: 0.41-0.65) for capsulorhexis skill and global skill, respectively. CONCLUSIONS: Time as an objective measure of skill was limited in its ability to distinguish between expert and novice skill class in a meaningful way.

Pharmacologic pupillary constriction after dilated fundus examination for ectopia lentis to prevent further subluxation.

PURPOSE: To describe two cases of ectopia lentis with different preoperative management strategies following the initial diagnostic dilated exam. OBSERVATIONS: In both cases, the patients presented with bilateral subluxation of the crystalline lens. Neither patient had a known history of Marfan's disease, homocystinuria or other systemic disorders that affect the body's connective tissue possibly leading to lens subluxation. Patient 1 was sent home after dilated fundus examination with no special precautions. That same night, he developed severe right eye pain and further decreased vision. He was found to have complete dislocation of his right crystalline lens into the anterior chamber with corneal edema and an elevated pressure, requiring an urgent pars plana lensectomy. In our second case of ectopia lentis, patient 2 was examined prior to dilation and noted to have bilateral subluxation of the lens into the vitreous. Twenty minutes after dilation, the crystalline lens was noted to be in the anterior chamber in the right eye. The patient was laid supine for several minutes and once the lens was in the posterior cavity, she was given 1% pilocarpine in both eyes to constrict the pupil to prevent dislocation in the anterior chamber. Patient 2 had an uneventful perioperative period and did not suffer worsening subluxation after her initial visit. CONCLUSION AND IMPORTANCE: Unlike patient 1, patient 2 did not suffer further subluxation after her initial dilated eye exam, therefore avoiding a more arduous clinical and surgical course. Patients presenting with completely dislocated lenses may benefit from the reversal of pupillary dilation by being placed in the supine position and given reversal drops such as 1% pilocarpine prior to leaving the office. This method may help prevent complications from anterior lens subluxation and pupillary block glaucoma until definitive surgical managment.

Perceived difficulties and barriers to uptake of Descemet's membrane endothelial keratoplasty among surgeons.

Purpose: To determine barriers related to implementation of Descemet's membrane endothelial keratoplasty (DMEK) among corneal surgeons. Methods: This was a multicenter survey study of all corneal surgeons who participated in a DMEK wet lab organized by the Netherlands Institute for Innovative Ocular Surgery. Data related to barriers limiting uptake of DMEK surgery, self-perceived levels of competence, and difficulty with different steps of DMEK surgery were analyzed. Results: The survey response rate was 31% (22 of 72). The most common barrier to uptake of DMEK surgery identified was anxiety related to incorrect insertion of the tissue and the need to regraft (64%, 14 of 22), followed by anxiety related to tissue preparation (50%, eleven of 22). Surgeons also felt anxious regarding the possibility of rebubbling with initial DMEK (41%, nine of 22). Steps related to DMEK graft (76%) preparation, tissue insertion (41%), and graft unfolding (72%) were identified as the most difficult steps to learn by the respondents. Conclusion: The DMEK learning curve, especially for the novice surgeon, may be shortened by seeking educational resources, including wet labs and surgical videos. Eye banks may facilitate adoption of DMEK by making validated DMEK tissue more accessible to surgeons globally.

Self-perceived preparedness and competence among ophthalmology residents for open globe repair.

PURPOSE: To assess which surgical training resources residents find most useful for open globe repair. METHODS: A nationwide, survey-based, cross-sectional analysis of ophthalmology residents enrolled in accredited training programs in the United States was performed to determine the association of surgical training methods with self-perceived resident preparedness and competence for open globe repair. The survey was developed at the Wilmer Eye Institute, Johns Hopkins Hospital. RESULTS: The individual response rate in our study was 38.6% (118/306 participant responses from 24 programs). Pre-operative surgical planning, in the form of review of patient charts and case discussion with senior faculty, was associated with higher self-perceived levels of both preparedness and competence for several different steps of globe repair. Both supervised and independent lab practice on animal or synthetic eyes were also found to be significantly associated with increased levels of self-perceived competence, especially for steps that involved scleral and limbal reapproximation. CONCLUSION: Open globe repair is an important skill that all ophthalmologists must learn to master. To improve surgical training, residency programs must focus on developing a structured surgical curriculum that incorporates training for managing ocular trauma and open globes. Possible components can include implementation of pre-operative briefings and case discussion with faculty as well as, encouraging regular utilization of practice labs in a distributed pattern to consolidate learning among residents.

Resident and program characteristics that impact performance on the Ophthalmic Knowledge Assessment Program (OKAP).

BACKGROUND: To determine which resident and program characteristics correlate with ophthalmic knowledge, as assessed by resident Ophthalmic Knowledge Assessment Program (OKAP) performance. METHODS: An online survey was sent in June 2017 to all US ophthalmology residents who took the OKAP in April 2017. RESULTS: The survey response rate was 13.8% (192/1387 residents). The mean respondent age was 30.4 years, and 57.3% were male. The mean [SD] self-reported 2017 OKAP percentile was 61.9 [26.7]. OKAP performance was found to have a significant positive correlation with greater number of hours spent/week studying for the OKAPs (p = 0.007), with use of online question banks (p < 0.001), with review sessions and/or lectures arranged by residency programs (p < 0.001), and with OKAP-specific didactics (p = 0.002). On multivariable analysis, factors most predictive of residents scoring ≥75th percentile were, higher step 1 scores (OR = 2.48, [95% CI: 1.68-3.64, p < 0.001]), presence of incentives (OR = 2.75, [95% CI: 1.16-6.56, p = 0.022]), greater number of hours/week spent studying (OR = 1.09, [95% CI:1.01-1.17, p = 0.026]) and fewer hours spent in research 3 months prior to examination (OR = 1.08, [95% CI: 1.01-1.15, p = 0.020]. Lastly, residents less likely to depend on group study sessions as a learning method tended to score higher (OR = 3.40, [95% CI: 1.16-9.94, p = 0.026]). CONCLUSIONS: Programs wishing to improve resident OKAP scores might consider offering incentives, providing effective access to learning content e.g. online question banks, and adjusting the curriculum to highlight OKAP material. Step 1 scores may help educators identify residents who might be at risk of not performing as well on the OKAP.

National survey and outcomes of resident-performed cataract surgery in monocular patients in the United States.

PURPOSE: To identify nationwide policies surrounding cataract surgery in monocular patients and compare outcomes of those surgeries between residents and attending surgeons. SETTING: Wilmer Eye Institute, Baltimore, Maryland, USA. DESIGN: Retrospective case series. METHOD: Cataract surgery educators across the United States were surveyed on their policies concerning residents performing cataract surgery on monocular patients. A second survey assessed resident opinions on performing surgery in such patients. In addition, a retrospective chart review was performed of all monocular patients (n = 72) who had resident-performed and attending-performed cataract surgery at the same academic institution. RESULTS: Forty-seven residency programs responded to the survey. Although the majority of cataract surgery educators from these programs thought it was ethical for residents to perform cataract surgery on monocular patients, only 18 programs (38.3%) had implemented specific policies. The resident survey response rate was 39.1%. Residents were more anxious and did more preparation for monocular cases than for routine cataract surgery cases. Analysis of the comparative case series found intraoperative complications (9.7% versus 5.6%; P = .37) and postoperative visual outcomes were comparable between resident and attending surgeon monocular cases. The resident status of the surgeon was not predictive of an increased risk for complications (odds ratio, 0.98; 95% confidence interval, 0.13-7.55; P = .99). CONCLUSIONS: Although most educators and resident trainees deemed resident-performed cataract surgery on monocular patients to be acceptable, the majority of residency programs did not have specific guidelines for residents performing surgery on such patients. Outcomes of resident-performed cataract surgeries on monocular patients at the same institution were comparable to surgeries performed by attending surgeons.

Objective assessment of intraoperative technical skill in capsulorhexis using videos of cataract surgery.

PURPOSE: Objective assessment of intraoperative technical skill is necessary for technology to improve patient care through surgical training. Our objective in this study was to develop and validate deep learning techniques for technical skill assessment using videos of the surgical field. METHODS: We used a data set of 99 videos of capsulorhexis, a critical step in cataract surgery. One expert surgeon annotated each video for technical skill using a standard structured rating scale, the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric:phacoemulsification (ICO-OSCAR:phaco). Using two capsulorhexis indices in this scale (commencement of flap and follow-through, formation and completion), we specified an expert performance when at least one of the indices was 5 and the other index was at least 4, and novice otherwise. In addition, we used scores for capsulorhexis commencement and capsulorhexis formation as separate ground truths (Likert scale of 2 to 5; analyzed as 2/3, 4 and 5). We crowdsourced annotations of instrument tips. We separately modeled instrument trajectories and optical flow using temporal convolutional neural networks to predict a skill class (expert/novice) and score on each item for capsulorhexis in ICO-OSCAR:phaco. We evaluated the algorithms in a five-fold cross-validation and computed accuracy and area under the receiver operating characteristics curve (AUC). RESULTS: The accuracy and AUC were 0.848 and 0.863 for instrument tip velocities, and 0.634 and 0.803 for optical flow fields, respectively. CONCLUSIONS: Deep neural networks effectively model surgical technical skill in capsulorhexis given structured representation of intraoperative data such as optical flow fields extracted from video or crowdsourced tool localization information.