Surgery: Manual Small Incision Cataract Surgery (MSICS)

This video demonstrates manual small incision cataract surgery in a white intumescent total cataract. A watertight wound was constructed and the nucleus was delivered using the visco-expression technique. An IOL was implanted in the capsular bag and the wound was checked for the integrity.

Surgery Location: on-board the Orbis Flying Eye Hospital, Addis Ababa, Ethiopia
Surgeon: Dr. Rishi Swarup, Swarup Eye Centre, Hyderabad, India


This is a white intumescent total cataract, and this patient as well has pseudoexfoliation. So, we can anticipate some zonular weakness, and I might prophylactically put a capsular tension ring. We will start with the paracentesis, I’ll try and do the capsulorhexis first, and then go to the wound. I have noticed that this vision blue takes a little longer to stain compared to the trypan blue I’m used to. So, we’ll just leave it there for a bit. Wash the Vision blue out with balance salt solution. So, I can see that there’s some intumescence, I’m going to do a dispersive first and then a cohesive viscoelastic.

We try and make a radial incision in the conjunctiva first. And then you introduce your scissor, underneath the tenons, so that you can dissect both the conjunctiva and the tenons together, cut along the Limbus. And then give another radial cut so that you have good exposure for your wound.

So, as you can see, the anterior chamber is now deep, and hopefully, the anterior capsule has been flattened enough. So, we make a puncture, make a little flap, flap it down, I am going to start small and then spiral outward. Even though it’s intumescent, it’s not really tending to extend, which is a good thing. That does look a little smaller than I would have liked it, so I’m going to enlarge it a little bit. So, we have these two perforating vessels, which I’m not very happy about. If I go anterior to them, I’ll be too close to the Limbus. So, I’m just going to ignore them and go ahead and dissect anyway. That’s 5.5. The ideal incision depth is about 50% of the scleral thickness. And the way to gauge that is that you start seeing a little bit of gray.

Make sure the edges are joined up nicely. When you’re doing the scleral tunnel, start in the middle of your incision, and with gentle wriggling motion, extend the crescent blade into the cornea. And then, with gradual, circular movements you dissect the wound. It’s important to keep the heel of your crescent blade against the sclera at all times, so that you don’t have a premature entry. So you can see there’s some bleeding that’s mainly from the perferated to vessels, it’s important to have a good grip on the sclera when you’re doing this dissection, otherwise, the eye keeps turning and you don’t have good control. It’s important that your scleral tunnel is well extended on the sides of your tunnel as well. So you can see that I’m turning it sideways and making sure that the side pockets are big enough to accommodate any size of nucleus. The internal incision should be at least eight millimeters.

So I’m just going to make my entry now, you can see the anterior extent of my scleral tunnel very clearly, it’s demarcated by the blood in the tunnel. When you’re introducing your Keratome, make sure that you move the keratome side to side. That way you can be sure it doesn’t hitch onto the floor or roof of the tunnel, make a dimple, enter and then horizontalize, then cut on downstroke on either side. It’s important not to cut while withdrawing, otherwise your internal incision will cut back, and you can have wound leak. So, I have cut till the Limbus on both sides, which is essentially my landmark. I will now make my left side port. So, I’m going to just enlarge my capsulorhexis a little bit. So, I’ve made a little radial extension on the capsulorhexis there. That’s a fairly good size, it’s extended. So made a radial extension here as well. And now we’re going to try and prolapse, the nucleus out of the capsular bag and then collapse it out of the pupil. And once we have 50% out of the equator, we can express the nucleus out of the eye. So, I’m just going under the capsule here and giving a gentle hydrodissection, I’m going to turn the nucleus with the same cannula. There’s quite a bit of intumescent cortex there, just trying the other side again.

We have an edge here; I’m going to go underneath the edge and turn it superiorly. So, I’m just going to go and put some viscoelastic on top of the nucleus first to protect the endothelium. Then I’m going to just turn the nucleus a little more. Pushing the iris around the nucleus, and you can use the same cannula to express the nucleus out of the eye. This is another technique called visco expression.

So, we can see that the nucleus and most of the cortex is already out quite safely. I’m going to use a bimanual irrigation aspiration cannula. One could use a Simcoe or a single port cannula as well. If you’re using a single port cannula, you need to put an anterior chamber maintainer. So first I’m going to remove all the loose cortex in the anterior chamber. I’m being a little tentative because I know this patient has pseudoexfoliation. Because we have a fairly large rhexis, I don’t think I’m going to put an endo capsular ring. But if it was slightly small, it would have been a good idea. Because pseudoexfoliation as we know, is prone for weakness of the zonules, and that could have predisposed to phimosis of the capsule and further worsening of the zonular weakness.

So, as you can see here, I’m trying to direct the lens such that the haptic goes directly into the bag, it’s quite a deep anterior chamber, so sometimes that can be a little challenging. Additionally, in this particular case, the peripheral extension was inferior, so I can’t be 100% sure it’s going to go into the bag.

So, when you’re dialing, you just give a little bit of posterior pressure. And you watch as the superior haptic comes up, it’s going under the capsule which means that essentially your whole lens is in the correct plane. So, in this manual small incision, since you are putting it to through the main wound, it would be a good idea to try and put the first haptic into the bag as far as possible, and then you can dial the second haptic in or manually release it into the bag, like we used to in our ECCE days.

So, the follow up for manual small incision would be like any other cataract, except that you have to pay special attention to the wound, because we have a larger wound compared to a phacoemulsification. We need to watch out for wound leak, especially if wound construction has not been perfect.

3D Version

September 12, 2018

Last Updated: March 7, 2023

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