EyeWorld Asia-Pacific March 2017 Issue

39 EWAP CATARACT/IOL March 2017 by Liz Hillman EyeWorld Staff Writer MSICS and ECCE in the developed world Should surgeons still be trained and maintain skills in these procedures despite the prevalence of phacoemulsification? M anual small incision cataract surgery (MSICS) has been touted as an ideal technique in developing countries where phacoemulsification equipment is expensive and not readily available. What’s more, a phaco procedure may not be the safest option for the type of cataracts ophthalmologists in these countries regularly encounter. 1 But does MSICS and other extracapsular cataract extraction (ECCE) techniques have a place in developed countries where phaco is available, affordable, and the well-established gold standard? Is it something that should be taught in training? Is it a skill to be maintained? Luis de la O, MD , Torreón, Mexico, thinks so. It’s an important skill to learn and maintain if you are trying to be a versatile anterior segment surgeon, he said. Dr. de la O explained how MSICS would be especially useful in the case of a hard brunescent cataract where there is no soft cortex and the capsule looks atrophic with white dots of metaplasia. Such advanced cataracts, admittedly, are seen less frequently in developed countries. Dr. de la O said MSICS offers surgeons similar benefits to phaco cataract surgery—non- stitch, no patch, autosealing with astigmatism-friendly incisions. The more modern MSICS technique, credited to Sanduk Ruit, MD , Kathmandu, Nepal, involves making a sclero-corneal tunnel small external incision with a long tunnel that leads to a larger internal incision for a trapezoid-shaped wound. Luther Fry, MD , clinical assistant professor, Department of Ophthalmology, University of Kansas Medical Center, Kansas City, Kansas, wrote in his book Clinical Practice in Small Incision Cataract Surgery that “one of the small incision manual techniques […] should be in the armamentarium of every cataract surgeon.” Even those doing virtually all phaco, such as myself, will encounter the occasional rock hard cataract, which is probably better managed by manual technique. Anyone doing small incision manual techniques can be assured they are performing state-of-the-art surgery for their patients with results as good as with phacoemulsification.” 2 Dr. Fry told EyeWorld he still thinks that while “catarocks” can be phacoed, the time and ultrasound power’s effect on the eye results in a cornea that “tells you by the next morning ECCE would have been better.” Most young surgeons in the U.S., however, have not performed ECCE in residency, Dr. Fry said. Due to the prevalence of phacoemulsification in developed countries, Chen et al. wrote that the role of ECCE is “unclear.” 3 A few years ago, Chen et al. published a survey of ophthalmology chiefs in the U.S. Veterans Health Administration (VHA). They asked if ECCE was performed at their facility, if so, at what percentage, and if they trained residents in ECCE. The survey, sent to 88 VHA facilities, saw a 42% response rate and showed that manual ECCE was performed at 72.2% of facilities composing an average of 2.2% of cataract surgery cases. The most common reason for performing ECCE was dense cataracts. Most of the facilities that responded were training residents in general but not in ECCE techniques. Facilities that did train residents in ECCE reported the most common reason for doing so was to prepare trainees in case they ever needed to convert from phacoemulsification. “The study suggests that most VHA facilities no longer train residents in manual ECCE. This is a concern because the manual ECCE technique is used in more than 2% of all cataract surgeries and for selected indications,” Chen et al. wrote. For further perspective, a large- continued on page 40 Dr. de la O and his daughter, Stephanie de la O, MD, perform MSICS. Source: Luis de la O, MD