EyeWorld India March 2019 Issue

43 March 2019 EWAP CATARACT / IOL MSICS and its place in the hands of young eye surgeons by Liz Hillman EyeWorld Senior Staff Writer Experts agree that manual small incision cataract surgery has a role in regular practice and training programs, even in developed countries W hile phacoemulsification has been the gold standard of cataract surgery for decades, a low-tech procedure—manual small incision cataract surgery (MSICS)—has carved out a place for itself, especially in developing countries where phaco is not as readily available. However, some think there is a place for it in the U.S. as well. “I use MSICS as a planned primary procedure in my own practice several times each year,” said David F. Chang, MD, clinical professor, University of California, San Francisco. “It is sometimes safer than phaco for the most advanced, ultrabrunescent cataract, particularly when comorbidities, such as phacodonesis, corneal endothelial dystrophy, or pupillary membranes and synechia, are present.” For similar reasons, Julie Schallhorn, MD, assistant professor of ophthalmology, University of California, San Francisco, and Matthew Oliva, MD, Medical Eye Center, Medford, Oregon, think MSICS should be incorporated into residency training programs, even if phaco is the most common course of cataract surgery. “I think it is critical that residents learn to make self- sealing scleral tunnel incisions and understand how to deliver a nucleus manually,” Dr. Oliva said. “This is a critically necessary skill in cases with a zonulopathy or if a phaco case is going poorly. I routinely do MSICS in my clinical practice several times a month for dense or unusual cataracts. The corneal endothelium does much better with MSICS than phaco in rock hard cataracts.” In addition to finding it valuable in dense cataract cases, Dr. Schallhorn pointed out that MSICS combines many surgical techniques that are important for any anterior segment surgeon to know. “For this reason, we start residents with MSICS as their first cataract surgeries as primary surgeon in the first year of residency. We begin the year with an intensive, week-long wet lab introduction to microsurgery and MSICS,” Dr. Schallhorn said. There is a bit of a learning curve to MSICS, Dr. Chang said, but it’s less steep for surgeons who have already learned large incision manual extracapsular cataract extraction. “Large incision manual ECCE should ideally be a part of everyone’s surgical armamentarium,” Dr. Chang said, explaining how it can be used with extreme zonulopathy, a zonular dialysis, or converting from phaco following a presumed posterior capsular rupture. “When converting from phaco, one can abandon the phaco incision and make a traditional large limbal incision superiorly,” he added. “With a soft eye, it is difficult to make the large scleral pocket incision that is required for MSICS.” However, most residents aren’t learning ECCE nowadays. 1 Dr. Schallhorn, for example, said she only learned MSICS in residency and it is the only extracapsular cataract surgery that she performs. “The major difference between these two procedures is the incision size and structure. With MSICS, you create a ‘frown’ scleral tunnel incision size that is often times self-sealing,” Dr. Schallhorn said. “During nuclear delivery, the lens will mold to fit the incision. With traditional extracap, the incision is more anterior and much larger, exposing the eye to longer periods of hypotony and requiring multiple sutures for closure.” Regarding the learning curve, Lynds et al. performed a retrospective case series looking at the outcomes of resident MSICS at a Dallas hospital. 2 The investigators concluded that the learning curve appeared most tied to the wound construction, but the procedure was safe and efficacious on the whole. “With several advantages over phacoemulsification, such as cost and ability to remove very dense nuclei, manual SICS will play a valuable role in cataract surgery,” Lynds et al. wrote. How to perform MSICS Dr. Oliva’s first piece of advice for learning MSICS is to work with an experienced MSICS practitioner who can step into the case if needed. Start with easy cases, those with good exposure, dilation, and mature cataracts, avoiding micropupils, loose zonules, and pseudoexfoliation cases early in the learning curve. “One of the challenges of MSICS for the beginning surgeon is that complications to the eye can be quite severe,” Dr. Oliva said. For example, poor wound construction can lead to Descemet’s detachment or iris trauma. Another pearl he offered is to grasp the eye just lateral and posterior to the wound edge— rather than grasping the wound itself—and rotate it downward with 0.12 forceps. For the wound, Dr. Chang constructs an 8-mm temporal scleral tunnel incision, dissecting it anteriorly into clear cornea with a crescent blade. He finds the can- opener capsulotomy useful after staining, especially because of the comorbidities generally associated with these cases. Dr. Chang hydrodissects the nucleus with irrigation from a Simcoe I/A tip, which he also uses to help extract the nucleus and remove cortex. Dr. Chang will usually implant a A preoperative black lens with posterior synechiae, shallow anterior chamber in a 60-year-old patient with retinopathy of prematurity. Continued on page 44