EyeWorld India March 2019 Issue

45 March 2019 EWAP CATARACT / IOL 9LHZV IURP $VLD 3DFLÀF Marcus ANG, MD Consultant Ophthalmologist, Cataract, Cornea & Refractive Service, Singapore National Eye Center Associate Professor, Ophthalmology and Visual Sciences DUKE-National University of Singapore 11 Third Hospital Avenue, Singapore 168751 marcus.ang@snec.com.sg I enjoyed the perspective and agree with most of the points shared in the recent article. In most developing and developed countries in Asia today, many patients present with dense cataracts sometimes associated with shallow anterior chambers and small pupils. Thus, techniques such as extracapsular cataract extraction (ECCE) and manual small incision cataract surgery (MSICS) are indeed useful for both young as well as senior eye surgeons in Asia. In fact, during my training it was mandatory to perform at least 100 ECCE cases before VWDUWLQJ SKDFRHPXOVLÀFDWLRQ , KDG OHDUQHG XVHIXO VNLOOV VXFK DV KRZ WR PDLQWDLQ anterior chamber stability through a large wound, maneuvering instruments in the anterior segment safely, and developing a passion for cornea suturing— SURÀFLHQFLHV IURP ZKLFK , DP EHQHÀWLQJ IURP DV DQ DQWHULRU VHJPHQW DQG FRUQHDO surgeon today. However, today many young eye surgeons start their training with SKDFRHPXOVLÀFDWLRQ RQO\ DQG DV VXFK PD\ ODFN H[SHULHQFH LQ SHUIRUPLQJ PDQXDO cataract extraction. 1 I still perform MSICS in complex situations such as phacodonesis and/or hypermature cataracts, or when in rural areas of Asia where most patients present with dense cataracts and the electrical supply is not reliable (www.global-clinic. org). The main advantages of MSICS over ECCE include a potentially self-sealing ZRXQG QRW UHTXLULQJ PXOWLSOH VXWXUHV³D NH\ EHQHÀW LQ UXUDO DUHDV ZKHUH SDWLHQWV may not return to the hospital for suture removal later on. 2 However, as a surgeon ZKR WUDQVLWLRQHG IURP (&&( WR SKDFRHPXOVLÀFDWLRQ WR 06,&6 , REVHUYHG VRPH NH\ FKDOOHQJHV DOVR VKDUHG E\ \RXQJ H\H VXUJHRQV ZKR VWDUWHG WKHLU WUDLQLQJ GLUHFWO\ ZLWK SKDFRHPXOVLÀFDWLRQ RQO\ $SDUW IURP WKH GLIÀFXOW\ RI FRQVWUXFWLQJ D self-sealing scleral tunnel, early MSICS surgeons unfamiliar with manual cataract surgery may inadvertently disrupt the scleral tunnel with each step as instruments need to move in and out of eye in an unfamiliar upward posterior to anterior angle. 7KLV PD\ OHDG WR D ZRXQG WKDW OHDNV DQG DQWHULRU FKDPEHU LQVWDELOLW\ FKDOOHQJLQJ the young eye surgeon even further. 7KXV , KDYH DOVR PRGLÀHG P\ 06,&6 WHFKQLTXH IURP WKDW LQLWLDOO\ GHVFULEHG E\ Blumenthal and Ruit 3 LQ DQ DWWHPSW WR PDNH LW HDVLHU IRU \RXQJ SKDFR VXUJHRQV (See surgical video: https://youtu.be/ltP5xEujgA4. 6RPH NH\ SRLQWV IURP WKLV PRGLÀHG WHFKQLTXH GHVLJQHG IRU \RXQJ H\H VXUJHRQV LQFOXGH D ODUJHU VFOHUDO tunnel shaped to self seal but allowing easier nucleus removal; using viscoelastic to prolapse and deliver the nucleus instead of an irrigating vectis that may disrupt the wound and cornea in experienced hands; and using a 2.65-mm clear corneal WXQQHO DV WKH PDLQ LQFLVLRQ VLPLODU WR SKDFRHPXOVLÀFDWLRQ WKURXJK ZKLFK DOO WKH steps including continuous capsulorhexis, intraocular lens insertion, and irrigation and aspiration may be performed. This technique involves more familiar steps to the young phaco surgeon while maintaining anterior chamber stability during each step and minimizes disruption to the scleral tunnel to allow a self-sealing wound. References 1. Lynds R, et al. Supervised resident manual small-incision cataract surgery outcomes at large urban United States residency training program. J Cataract Refract Surg . 2018;44:34–8. 2. Ang M, et al. Manual small incision cataract surgery (MSICS) with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract. Cochrane Database Syst Rev. 2014:CD008811. 3. Ruit, et al. The role of small incision suture-less cataract surgery in the developed world. Curr Opin Ophthalmol . 2018;29:105–9. (GLWRUV· QRWH 'U $QJ GHFODUHG QR UHOHYDQW ÀQDQFLDO LQWHUHVWV M anual Small Incision Cataract Surgery (MSICS) has long been UHFRJQL]HG DV D FKHDSHU DOWHUQDWLYH WR SKDFRHPXOVLÀFDWLRQ DQG was more popular in the developing world. However, surgeons globally have realized that MSICS is indeed a useful technique to have LQ HYHU\ FDWDUDFW VXUJHRQ·V DUPDPHQWDULXP , GR EHOLHYH WKDW ERWK manual extracapsular cataract surgery and MSICS should be taught to residents during their surgical training. This technique will be useful WR WKH VXUJHRQV GXULQJ H[WUHPH FKDOOHQJHV VXFK DV EODFN FDWDUDFWV brunescent cataracts, or suspected zonulopathy. There are several other advantages of learning MSICS, such as learning scleral tunnel construction, capsulotomy, and nucleus delivery into the anterior chamber. The ability to create a lamellar scleral WXQQHO FRPHV KDQG\ LQ VLWXDWLRQV VXFK DV VFOHUDO À[DWLRQ RI ,2/V trabeculectomy or other complex surgeries. Samaresh SRIVASTAVA, MD Consultant, Raghudeep Eye Hospital $ 6KDQWL 3DWK 7LODNQDJDU -DLSXU Rajasthan 302004, India samaresh@raghudeepeyeclinic.com ...surgeons globally have realized that MSICS is indeed a useful technique to have in every cataract surgeon’s armamentarium. – Samaresh Srivastava, MD MSICS is often propagated as a sutureless surgical technique. However, , ZRXOG OLNH WR FDXWLRQ VXUJHRQV LQ WZR DVSHFWV )LUVW , EHOLHYH WKDW DQ\ tunnel incision that is wider than 5.5 to 6 mm may not be self sealing, and therefore I would put in at least one suture if the incision size is ODUJHU WKDQ PP 6HFRQG DV ZLWK SKDFRHPXOVLÀFDWLRQ WKHUH LV D WUHQG of reducing the incision size with MSICS. The incision size should be carefully titrated depending on the grade and size of the nucleus, the VXUJHRQ·V WHFKQLTXH DV ZHOO DV H[SHULHQFH 2IWHQ WU\LQJ WR GHOLYHU a large nucleus through a smaller incision may give rise to serious complications such as endothelial trauma or iris trauma. Therefore, to begin with, surgeons may want to start off with larger incisions, and slowly go to smaller ones as their comfort level improves. In terms of patient selection, I would advise beginners to start with moderate density nuclei, such as nuclear sclerosis grades 2 and 3. Choosing extremely dense or extremely soft lenses in the initial OHDUQLQJ SKDVH PD\ QRW EH D JUHDW LGHD DV LW EHFRPHV GLIÀFXOW WR GHDO with both extremes. $V UHJDUGV FRQYHUVLRQ RI SKDFRHPXOVLÀFDWLRQ WR 06,&6 LQ FDVHV RI posterior capsule rupture, I would put in a word of caution. In an open posterior capsule, if the incision is enlarged and ECCE or MSICS is performed, the pressure during nucleus delivery may in fact cause more vitreous prolapse and traction on the vitreous base. There could be long- WHUP GHOHWHULRXV FRQVHTXHQFHV RI FRQYHUWLQJ IURP SKDFRHPXOVLÀFDWLRQ to any form of extracapsular surgery. Therefore, I would not recommend doing this as a general approach, but only in certain select situations, and that too in the hands of an experienced surgeon. (GLWRUV· QRWH 'U 6DPDUHVK 6ULYDVWDYD GHFODUHG QR UHOHYDQW ÀQDQFLDO LQWHUHVWV