Lecture: Mastering MSICS Surgery: The Mentorship, Cases, and Techniques

In this highly interactive and video-based webinar, three SICS surgeons will reveal tips and techniques garnered through decades of practice and mentorship throughout their careers. Each speaker will delineate specific steps as a demonstration for the audience. Audience members will view novel approaches to MSICS surgery as they look to incorporate these strategies into their practices. This webinar is dedicated to Dr. Ravi Thomas who made MSICS training, research, and promotion a cornerstone of his vibrant career. (Level: All)

Moderator: Dr. Parikshit Gogate, Ophthalmologist, Dr. D.Y. Patil Medical College, Pimpri, Pune, India

Dr. Nitin Tulsyan, Ophthalmologist, Ram Kumar Mahabir Prasad Kedia Eye Hospital, Nepal
Dr. Haripriya Aravind, Ophthalmologist, Aravind Eye Hospital, Chennai, India
Dr. Sarwar Alam, Ophthalmologist, Ispahani Islamia Eye Institute & Hospital, Bangladesh


PARIKSHIT GOGATE: Good morning, good afternoon, good evening, because you’re all from different parts of the world. So we have here a special Cybersight webinar, it time on manual small incision cataract surgery. And we have three phenomenal speakers from the Indian subcontinent, from three different countries, each one of them with a different perspective and experience in doing manual small incision cataract surgery. So without much ado, let’s start with the webinar. So I’m Parikshit Gogate, an ophthalmologist based in Pune, India. I’ve been doing manual small incision cataract surgery for the past 25 years. I became a phaco surgeon first. In many areas MSICS can be the surgery of choice. In fact Orbis International had commissioned this manual or manual SICS way back in 2005, almost 20 years ago, when two doctors had asked Professor Ravi Thomas and another doctor to compile this. Professor Thomas was at that time the Director of the Tilganga Eye Centre. And we are having this webinar in the memory of Professor Ravi Thomas. Professor Thomas is a teacher par excellence. He was born in Raipur in a forested tribal area in central India. I think perhaps his upbringing in that very poor remote region, with parents who had missionary orientation, put him on the path to do what he did in life. He was the head of ophthalmology at Christian Medical College, then the Director, then finally as a Professor at Queensland Eye Institute in Sydney. To his students he always taught that the eye care to be delivered has to be of excellent quality, it has to be equal to anybody, and we have to have a lot of compassion, good feeling for our patients, because that is what they have come to us, not just to get their eyes fixed, but as human beings who need care. And in fact, the three speakers that we have today are also from three institutes who each one of them followed this quality, equity, and compassion that Professor Ravi Thomas so passionately taught in his life. This is the webinar. We have Dr. Nitin Tulsyan, Dr. Haripriya Aravind, and Dr. Sarwar Alan, and they’ll be showing you various videos of manual small incision cataract surgery. You can ask questions on the side board and they will be more than happy to answer you. First we have Dr. Nitin Tulsyan. He is from RM Kedia Eye Hospital. He is the medical director there, a well-known pediatric ophthalmologist with interest in the research and teaching. Dr. Haripriya Aravind is of course a star in Indian and global ophthalmology. She’s had so many sessions in the American academy with numerous publications and awards to her credit. She heads the Aravind Eye Hospital in Chennai. It is perhaps the largest practice in the world. They do more than 300,000 surgeries every year, correct me if I’m wrong, Dr. Haripriya. 60 or 70% of them is done completely free of cost. In fact we can say it’s where manual small incision cataract surgery really flowered and perhaps the first institution to shift to that for all its nonpaying patients and paying patients too. Finally, Dr. Sarwar Alam, an ophthalmologist and head of the education department at the Isphani Islamia Eye Institute. They do a lot of work completely, again, free of cost or at very last cost and is a very famous training center in its own right. So I think we will now start off, I’ll hand this over to Dr. Nitin Tulsyan, a friend and colleague. Over to you, Dr. Nitin, please go ahead. >> NITIN TULSYAN: Thank you, Dr. Gogate. Just to correct you, I am not a pediatric ophthalmologist, I am a surgeon. So thank you, and I’m obliged to be a part of this webinar. I’ll go straightaway to my presentation in the interests of time. So I’ll be talking regarding techniques and complication management of sclerocorneal tunnel construction. I am medical director and vitreo cataract surgeon. To begin this surgery, we first perform a conjunctival peritomy. We take the forceps and go in cut the conjunctiva and the limbus. What is the benefit of the peritomy? To expose blue limb balance zone without overhanging conjunctiva. So few surgeons prefer to use wet field cautery. It allows proper visualization of the instrument, prevents or minimizes bleed into the anterior chamber. So the points to consider, point cautery should be applied to scleral bleeders only. Cautery of limb balance blue zone bleeders has to be avoided. And cauterizing without proper tenons fascia removal may cause inefficient cauterization. It may cause fishmouthing and subsequent wound leak. So the construction of triplanar sclerocorneal tunnel was first introduced by Paul Ernest. It has three components. This is the picture which clearly shows what are the components. We can see this is the external incision, and then the internal incision. There is the flap of the conjunctiva deflected. In these pictures we can see how first we give a scholarly incision perpendicular to the surface. One is slope or perpendicular. The wound is nicely opposed, whereas some gapping in the wound. And the different types of incisions we can use is a smile incision, straight incision, frown incision, Chevron incision, and inverted bat wing incision. It depends what surgeon basically prefers, because it’s all the surgeon’s choice. I’ll tell you later what is the best incision to be given. So the astigmatic neutral funnel, it is directly proportional to the cube of the length of the incision. The longer the length of the incision, the larger will be the distance from the limbus. It doesn’t mean that we go too much away from the limbus, because the normal distance from the limbus should be 1.5. If you go beyond that, then there might be a prolapse. So, location is usually the convex part of the frown incision is along the posterior limb balance line. We can see it mentions frown incision, so the best incision will be frown. This corresponds to 1.5 millimeter from conjunctival insertion. Ideal incision depth should be half to three-fourths of the scleral thickness, it should be uniformly deep along its length. If there is less than 50%, there might be thin roof or button hole during tunnelling. If you go 100%, then scleral disinsertion or ciliary prolapse risk. So how construct the tunnel using crescent blade, gentle wriggling and swiping movements. Uniform thickness sclerocorneal tunnel extending up to 2 to 3 millimeters into the clear cornea. Tunnelling forward, raise the tip and depress the heel of the blade, and move forward. Sideways swiping movement. So in this picture we can see the incision point. And then the scleral tunnel. This is the movement, wriggling movement. So how we enter into the anterior chamber. One is, we can move a swinging movement of the cannula or use a sideways movement which I’ll show you in the videos. Once we enter the anterior chamber and go sideways, starting in this picture we can see. The incision will be frown externally and smile internally. So internal corneal incision is constructed using keratome. The heel of the keratome raised to create dimple on corneal surface. This is a diagram presentation. How long the incision should be and how much to go into the clear cornea. So advantages of tunnel, in case there is hemorrhage, it can be managed by simply removing the instrument because the wound will close. Respiratory or cardiac incidents can be dealt with by removing the instrument during resuscitation period. Post operative, decreased iris prolapse, avoidance of hypotony. This is a video of mine. We’ll show how a peritomy is performed. We are cutting the conjunctiva tenons. The globe is stabilized, you can proceed further. Frown incision, and moving anteriorly center. Side by side movements. The blade is visible clearly anteriorly. And once we go 2 millimeter into this cornea, then sideways movement towards the corners. Now to the other side. Side by side movement, sweeping. So now I move one end to the other end. So this is how I created a tunnel. Now entering into the anterior chamber. I’m going to stabilize the globe. And then side by side movement, going up to the tip of the tunnel, then down. And we cut the internal incision while going inside. So the wound is entered. And you can see at the end of the surgery, if your tunnel is perfect, the wound will close nicely. >> PARIKSHIT GOGATE: Dr. Nitin, we have a few questions, if we can answer them. How to decrease risk of full stop astigmatism and similarly, how to decrease the postop [indiscernible]. All of them have the same question. I know you showed it, but if you can just make a quick comment. >> NITIN TULSYAN: Yes, I’ll just say what I said previously, the length of the incision and the distance of the incision from the limbus. So the length distance will be 1.5 mm from the limbus. How big the incision should be, since we are doing it, to avoid astigmatism. If it’s less than that, there might be complications during nucleus delivery. If it’s more than that, that will cause more astigmatism. If you go beyond 1.5 mm from the limbus, then there are chances of premature entry and other more complications. And coming less than 1.5 mm, the wound will not close properly, there will be chances of causing damage to the cornea. So that will cause more astigmatism. There might be chances that you might have to apply sutures. When you apply sutures, there will be more astigmatism. So MSICS is to avoid sutures and make a tunnel. So to avoid astigmatism, what we need to keep in mind is two things. The length of the incision should be around 6 mm and should be 1.5 mm from the limbus. Thank you. >> PARIKSHIT GOGATE: Thank you, sir. >> NITIN TULSYAN: We can’t hear you, Dr. Gogate. >> PARIKSHIT GOGATE: We had a similar question. Please go ahead with your video, sir. >> NITIN TULSYAN: So now I’m showing you a video of button hole. This surgery was performed by a resident, I just recorded it after the complication was done, basically. You’ll see this in this video. You see this, this is a button holing in the sclera. Now managing the incision, it was very much superficial. I made another plane of the incision. I just made another incision. I entered from the other corner. Deeper to the button hole. >> PARIKSHIT GOGATE: So you have left the first plane and you created — >> NITIN TULSYAN: Yes, I just created a deeper plane. Because the first plane was quite superficial. There was enough space to create another plane. The new plane is created. Now in the next — sorry. In the next video, I’ll show you. After completion of the surgery. The this is the button hole area. The wound is well opposed. So now, since the wound was superficial, I managed to do it by making a deeper plane. Just in case the surgeon was in the proper plane and they had created a button hole, what we would do is we just had to suture. Suppose the button holing is in the cornea even, if there is button holing, we have to apply sutures. This is not my video, sorry for that, I stole it from YouTube. This is premature entry management. And this, I’ll just show how do we do it. While making a tunnel, there is abrupt entry into the anterior chamber. Now the anterior chamber is entered. So after completion of the surgery, I’m short of time, so what you do at the end is, we apply sutures. So there is no other option, when there is a premature entry, we have to apply sutures, because initially the wound might be opposed when you close it, but later on, with minimal trauma or even during dressing of the wound next morning, the wound might leak. So it’s better to be on the safer side, we apply sutures. And if there is prolapse, we do have to apply sutures. Sometimes there is no prolapse, even after premature entry. In that case also we should apply sutures. >> PARIKSHIT GOGATE: I think that’s a very important tip you gave us, Dr. Tulsyan, that sutures are very important and they are very much needed for safety. So whenever there is even the smallest bit of doubt whether to suture or not to suture, it’s always better to suture. >> NITIN TULSYAN: Yes, right. >> PARIKSHIT GOGATE: One question was asked, if you do the cautery, there may be a small amount of oozing but it does not interfere the surgery and postop astigmatism is always better if cautery is used. >> NITIN TULSYAN: Cautery is used. Now this is my second topic, descemets membrane detachment. I’ll do it fast. Because in this, basically this is simple detachment, this is postop. This is management during a phaco. While doing phaco, there was a detachment, we can see there is a hanging of the descemet membrane. If there is a detachment, minimal, small detachment, if the wound is nicely opposed, we can just do an [indiscernible] if the detachment folds on itself. If there is a big detachment that is not folding on itself, we can use gas. But generally what I do is, most of the time there is none. And the last topic is anterior capsular runout. This happens because unlike most routine cataracts, the cataract is fluid filled and has increased intralenticular pressure. The posterior pressure is exerted. So this is a video performed by my resident. While doing capsulotomy. There is extension of the capsulotomy. It’s getting extended. It’s getting extended here and on this side. Now it’s here. Now it’s almost done. So I’ll stop right there. What I did is, I entered the wound through the tunnel. How can we prevent this? The pressure should be more. When the pressure in the chamber is more, it doesn’t exchange. Another process of what we can do is give an nick in the center. The pressure in intraocular is increased and we can continue. In this way we can prevent the runout and the third is we can even do envelope technique, open the tunnel and give two nicks on the other sides and we can complete the surgery. To summarize my surgery, this is a video. Before the — >> PARIKSHIT GOGATE: We will have this at the end if we have time because we’ve already done 25 minutes. >> NITIN TULSYAN: This is my summary, sir. So we can see the surgery is complete. So this is from my side. Thank you. Now I have a polling question. Will I be showing the polling questions? >> PARIKSHIT GOGATE: We can show them at the end, sir, we have about 15 minutes for Q&A. Thank you. >> NITIN TULSYAN: Thank you, sir. >> PARIKSHIT GOGATE: Thank you, Dr. Nitin. There is more cataract surgery than another in the world because they do a lot of surgeries on Indian patients too. Over to Dr. Haripriya. >> HARIPRIYA ARAVIND: Thank you so much Dr. Gogate for this opportunity. Can you stop sharing the screen. >> NITIN TULSYAN: Yes. >> HARIPRIYA ARAVIND: I’ll be talking on the nucleus management. I think we had an excellent lecture about making the right tunnel. I think making the right sized tunnel and the capsulorhexis is important for managing the nucleus. Can I have the first poll question please, Andy. So the question is what is my preferred technique for nucleus extraction. Please answer now. Fish hook technique, irrigating vectis, visco expression, Blumenthal technique, and do not routinely do MSICS. We request all attendees to respond so we know how many of you are doing MSICS and which is your preferred technique. Thank you. That is a very interesting response. It seems like viscoexpression and irrigating vectis, followed by the fish hook, and 14% don’t do MSICS. At the end of this symposium hopefully we’ll have more of you attempting to perform this technique with of course appropriate guidance. 5% did the Blumenthal. Thank you for the responses. So the nucleus management includes both the nucleus prolapse and extraction. Prolapse is to move to the anterior chamber. And this prolapse, you need to have a good sized vectis and large enough pupil. Now, to be able to have the right size, it’s important that the surgeon also be able to estimate the size of the nucleus properly, which happens with time. That’s why initially when a surgeon starts doing SICS, it’s better to have a softer nucleus and are more malleable. One would have to make further modifications to prolapse the nucleus without any problem. For the nucleus prolapse, the most commonly used techniques for an immature lens is the hydroprolapse. This especially would require large capsulorhexis. So with the hydrocannula, one will have to take the cannula and introduce it. So you have a cortical clearing hydrodissection. You can see the fluid. And one pole coming out. In this case, the same cannula, the hydrocannula, is used. Then lift and rotate the nucleus to bring it to the anterior chamber. So like I said, doing a cortical cleaving hydrodissection will bring the nucleus out. This makes your nucleus extraction and cortex aspiration a lot more efficient. If you had a smaller vectis, the epinucleus has to be moved. The second option in case the nucleus is not prolapsed or in a brown or white lens, the other option is mechanical prolapse of the nucleus. I think all of these techniques, it’s important to have an adequate capsulotomy. When doing a mechanical prolapse, if we’re doing a can opener, we don’t do hydro. It’s good to have the nucleus, I normally advocate this for beginners, from the center go to the periphery, and then lift one pole. And then you will get a good firm hold on the nucleus which will then enable you to prolapse the nucleus completely into the an for your chamber and it can then be introduced below the nucleus, irrigation from the vectis helps to move the nucleus along with the mechanical forces. Talking about nucleus extraction, the most commonly done technique in our institution is using the irrigating vectis which is what most of our surgeons use. We use a vectis here with three different points. The vectis is introduced, once it’s under the nucleus, and ensure there is holding the nucleus well. At this point, where the superior bowl of the nucleus is engaged in the tunnel, at this point reaction are critical. One, you have to depress so the tunnel opens without much damage. Second of course you have to hold on to the suture or hold on to the globe. So the globe stability is important. And third, you also inject the fluid. And the hydrostatic forces also helps extraction along with the mechanical forces. Doing all of this after the superior pole is engaged tends to have a very comfortable nucleus extraction along with the right size between the tunnel and the nucleus. Like I said, will you have to check. Ensure that it goes under the nucleus. Press the lip and then you can gently extract the nucleus. >> PARIKSHIT GOGATE: You always take the superior vectis in the suture? >> HARIPRIYA ARAVIND: I prefer to go temporally in almost all cases because of astigmatism. >> PARIKSHIT GOGATE: Regularly when you do it. >> HARIPRIYA ARAVIND: Because most of them have a steeper horizontal meridian so I normally go temporal. In a young patient I go superior. Otherwise, almost always I go temporal. I hold the conjunctiva. So one can — a beginning surgeon, a suture will be useful because you get ahold. Then we choose to migrate, holding the globe with the forceps for tunnel construction and for the nucleus extraction as well. The other technique as an option would be the phaco sandwich. I don’t do much of this personally, but this probably is a technique which some surgeons would use for a harder nucleus. If you want a smaller incision, you sandwich the nucleus and remove it. You can remove the nucleus for a smaller wound. Now, this can work in brown lenses. Please remember that the vectis has to be held in the nondominant hand which for most of us is the left hand. That is inserted first. So we may get confused, we always use the vectis in the right hand. So insert the vectis first which is held in the nondominant hand, then the hook goes above it, to sandwich the nucleus. Now, one has to remember that this can cause a little bit of crowding in the anterior chamber because you have a large nucleus and two other instruments. One has to be conscious of this. It also helps to have your assistant stabilize the globe, otherwise the globe may move towards you when you’re trying to remove the nucleus. Again, as I said, most of us do the technique, it’s interesting to see there’s a varied response from the audience. Each one has — quite a few are doing the fish hook. Whatever works well in your hand is fine as long as your outcomes are good, your cornea is clear, and you have less chance of complications either intraop or post-op. In case you have a brown cataract, one has to modify the technique. You have to see the patient preop. Start with the softer lenses. Once you go to brown lenses, consciously make a larger tunnel obviously to extract this large nucleus through this wound. Large pupil is also mandatory. You may have a little more controlled hydrodissection and do not plan for hydroprolapse, because it may not actually come out, if you have a large, bulky nucleus, it’s about 8 to 9 millimeters, maybe 6 millimeters, and it’s not as malleable as a soft lens, it may not come out. So plan for a mechanical prolapse when dealing with a brown cataract. A large vectis is mandatory here. Elderly patients have thin capsules. That enables us to make a large vectis. In case you have a small vectis, and then prolapse. Hook the equator, bring it out. Once you have a large vectis, you find this mechanical technique works well, go to the periphery, hold the equator of the nucleus and bring it out. You’ll see even in this black, not brown cataract, that is important for us to be able to see before you extract to prevent any dialysis. This is an alternate technique. A bimanual technique I think is very useful, please note that the dominant hand, using the hook, nondominant hand, you can either use the hook or use the spatula, I use the spatula in the nondominant hand. Once you have the first pole come out, from the center go to the periphery, then you rotate the nucleus and the spatula goes below it. This acts like a support system under the nucleus. You can rotate the rest of the nucleus. At this point I go back and use support which prevents the nucleus to go back into the capsule. I can use it as a sandwich, hold it from below and above and help bring out this large nucleus. This bimanual technique works very well. If you have a larger nucleus. But please remember this is no compromises, because you have a large nucleus and you have a bimanual technique, you will still have to have a large enough vectis, otherwise the nucleus will not prolapse out, and there may be a compromise to the capsule. This other case is to show you for nucleus extraction. Like I said, I almost always insist that surgeons bring the nucleus into the anterior chamber completely and then extract. This could be one exception, which is in a hypermature lens. A capsulorhexis is being done here. Make sure that the capsulotomy is large enough, we don’t want to compromise an already weak capsule bag. This lens is dislodged. It’s a small nucleus but also very hard one. And this may not be easy to prolapse. Once this is loosened up, you can still use a vectis, and then remove your nucleus, because here it is loose. Otherwise if you try to take your nucleus out using your vectis with a partially prolapsed nucleus, you have a higher chance of dialysis. Always remember to focus on bringing the nucleus out into the chamber first and then do a prolapse with your vectis. What happens when you have a slightly smaller pupil, make sure you’re using the sphincterotomies. WAN can increase pupil stretchability. It’s very important to have a flexible pupil to bring the nucleus out into the anterior chamber. In spite of the sphincterotomy, if you use a can opener, a hydroprocedure is not used. One can either consider a mechanical prolapse or bimanual prolapse in the small pupil. Obviously a hydroprolapse will not work. There’s no point doing that again and again. Just do a good hydrodissection and then a mechanical prolapse. If you’ve done a capsulorhexis. If a can opener, you can go straight in and do a prolapse. This patient has a small pupil, a white lens, but it’s hard, the patient is elderly, I make a larger tunnel. I make four small nicks. I like to make it four because it gives it uniform stability. The pupil, of course it’s still not too disfigured so I normally do that. As mentioned, make your capsulotomy larger than your pupil side. It has to go below the iris. A can opener works perfectly fine. Ensure you have a good can opener. Take it all the way out 209 periphery and then rotate as you’re lifting it, also rotate it. You can see the pupil is small but it’s able to accommodate this large nucleus because that is the power of the sphincterotomy. It gives you that flexibility which can accommodate a large nucleus. Sometimes we find prolapse doesn’t work, one can consider to push the nucleus back and then do a sphincterotomy or try to prolapse it out. With a can opener, you will use an Sinskey hook. You can see this is a hypermature lens. A capsulorhexis is initiated but it does not seem to work. There is a lot of fibrosis. You don’t have to have it, if you have it it’s good. Otherwise a can opener works just fine, especially in brown and white lenses. Just ensure you’re having a completely large enough capsular opening. You hook it from the periphery. First you go to the anterior surface, move it to the other I had, get one pole out, then you’ll see you’re able to rotate the nucleus out. Once this is done, then you use your vectis. I don’t use irrigation here. The fluid can cause more prolapse. The bag is there but as we know there’s no zonules in this one cataract. Now, what is the most — I like to bring up the next polling question just to hear from the audience. >> PARIKSHIT GOGATE: In four or five minutes we have to hand over. >> HARIPRIYA ARAVIND: Sounds good, that will be perfect. What is the most common difficulty I face with the nucleus prolapse? Please respond. Is it cheese wiring, is it that the prolapsed pole slips back into the bag, or the pupil constricts and is enable to prolapse, nucleus is stuck to the pupil, or I do not routinely perform MSICS. I’m sure all of us have had these issues. Again, there’s a fairly good distribution, most commonly being the prolapsed pole slips back into the bag. Making a bimanual prolapse will help this. Pupillary constriction, I know we normally don’t like — that’s probably the most effective thing to do when stuck with a small pupil. Other complications could be the nucleus is stuck in the pupil or there could be some cheese wiring as well. Cheese wiring mostly happens because very soft lenses. Make sure you have a large vectis and too a good hydroprocedure that can make it much easier than trying to prolapse it out mechanically. If the pole tends to, you know, slip back, make sure that the force is always upwards. As you dial, put the scope between the prolapse as soon as you remove the Sinskey or support it with a second instrument below. This works very well as well. Just to show you a situation, you hook the anterior capsule, this is a mock surgery in a wet lab scenario. This is what happens, right? We tend to have a — this can happen because the pupil is too small, you don’t know where your Sinskey is being placed. To manage this, you go to the opposite site, lift the bowl, continue on the side of zonular dialysis, use your spatula and bring the nucleus out with both instruments. This way you will be — this is probably a three to four clock hour zonular dialysis. This ensures you can still have your bag there. This is actually a patient with subluxation. I’m showing you as to how you can manage, this is a zonular dialysis during your prolapse. You will first — this is a larger one — >> PARIKSHIT GOGATE: In another two minutes we’ll hand over to Dr. Alam. >> HARIPRIYA ARAVIND: Yes. You will have to get one pole out, the opposite side, get it out into the anterior chamber. No hydrodissection here, support the capsular bag, and remove the cortex completely before it’s placed you. May miss the bag. If you have a zonular dialysis, with the hook still in place, it’s guided. And then it goes in the bag with the hook still in place. So court ex aspiration, you can use the Simcoe cannula. Please remember, the aspiration port is in the front, in the tip. Irrigation port is in the side. Ensure the aspiration port is occluded. One important tip which all of us do is go to the side port for two reasons, to remove the cortex and to prevent any positive pressure which is also not uncommon with the large tunnel which we have. And finally, I’m just talking about IOL implantation. I am placing a single piece lens. Ensure both go in the bag to distend the bag with. Why do a single piece? We actually did a controlled trial where we compared the round and the square and we saw them up to nine years postop. We saw a huge difference, a huge benefit when we use the square edge. This I think is a great option which we give for our outreach patients. They don’t have to come back to us later on for issues. Thank you again for this wonderful opportunity. >> PARIKSHIT GOGATE: Thank you, Dr. Haripriya. The nine-year is awesome for cataract surgery, it’s unheard of. Thank you, Professor Alam, if you can share your videos. Thank you, ma’am. We will have questions at the end and you can interact with all the speakers. >> HARIPRIYA ARAVIND: Thank you, sir. >> SARWAR ALAM: Hello, everyone, I am Sarwar Alam from Bangladesh. It’s a pleasure to be with you. The share has not been closed. >> PARIKSHIT GOGATE: You can share your screen, the green square at the bottom, sir. >> SARWAR ALAM: I don’t know what happened. In my presentation, I have no disclosures. The first polling question, how confident are you in performing the MSICS surgery? Very confident, confident, neutral, or not confident? Because most of are you definitely in the process of being a surgeon, so please express your expertise. So the answer is now about 17% is very confident, confident is 31%, neutral is 20%, not confident is 31%. Okay. Next slide, please. My first topic is the architecture and measurement of a standard wound. Architecture describes the number of the incision planes, uniplanar, biplanar, or multiplanar. Multiplanar produces watertight and stable incisions. Next, please. And some of the dimensions which already has been discussed, I am not repeating it. Next, please. And we have to have a conception of the different planes. The first is vertical. Next one. In the first plane, incision can be given. The first one is the straight one. And the second one is the frown incision and the third is bat wing or inverted frown. While it is difficult to master sometimes, many ophthalmologists prefer to suture. Next, please. And the second plane is the making of the tunnel and the scleral pocket. And already this has been discussed so I’m skipping this slide. Next one, please. And the third plane is already said, the dimple should be seen before entry. This is the enlargement of the incision. Instruments are preferred so no injury can happen. Next, please. Gross assessment of the depth of the tunnel. The transparency of the superficial flap over the knife blade. There might be chances of premature entry if transparent here, if we can see, thin flap, chances of button hole. You can see it might be a normal depth. Next, please. This is a good video which has been already shown, how the button hole occurred. Quickly, he went into much deeper plane and the button hole has been corrected. Next, please. And next is how to extend when you have a jumbo lens. We can see how large the nucleus is. First we have to access the nucleus size and use plenty of OVD because it is almost the whole of the anterior chamber. Then extension of the wound by a knife, crescent or blunt keratome. Next, please. Next topic is OVD. We maintain the volume and the shape of the AC and protecting the intraocular structures. Next, please. I’m sorry. When to use OVD. It can be used over the corneal surface for clarity. Before construction of the main wound, at the beginning and after completing each quadrant, after the hydro and before delivery. Next, please. Which OVD to use. There are so many things here. The basic thing is that there is a single mass that can be used. It disperses. Next one. Here is an example of dispersive. The first drop is cohesive one. It does not spread rapidly. It tries to maintain in the same place. We can wash it easily. But the second drop is dispersive one, it disperses more rapid than the other one. It is difficult to wash, it needed several times. It is sticking to the surface. Next one, please. But when OVD is not our friend, when we remove, forget to remove completely, we’re thinking only off the OVD in the anterior chamber. But in the posterior chamber, if we don’t remove, we have several complications like elevated IOP. Next, please. In the capsule stain, in the first case, the image 1, we can see very clearly the reflex can be managed without stain. In the second case, it is almost impossible without the stain. Next, please. And we can wash it with the BSS, then it is workable to have a good capsular stain and capsulorhexis can be done effectively. The air is injected into AC. It does not want to retain, so — okay. The next slide is a complication of giving — the previous slide, please. This is a capsulary staining going deep into the vitreous. The stain was given, and it was a hypermature case, so the stain went to the capsule. It is evident that it is in the vitreous. Next one, please. And this staining of the cornea, if you don’t understand why we’re injecting. Next, please. The next issue is the issue of the knives. And when we use the knife, second poll question is, what do you see in this picture? Injury to the lens capsule by the tip of the keratome, injury to the cornea by the tip of the keratome, injury to the iris by side of the keratome, or injury to scleral tissue by side of the keratome. So injury to the lens capsule, the maximum, 64%. So the first one. Next slide, please. First one is the correct answer. Next slide, please. There are several knives on the market. But whatever knife is used, for incision, disposable knives are widely used. Next one, please. We can see the BP knife used in the developing countries. It is less costly for making the first incision. Next one, please. I’m skipping this because it has been already shown. But previously slide was not guarded. Guarded knife blades are available on the market, less costly than the diamond knife. Next one. With this we can make the incision, we can also enlarge the incision. Next one, please. And 15 degree side port entry blade. Next one, please. This has been already discussed, many of the topics, so I am skipping. This is a blunt keratome. Care must be taken not to injure the structures. This is blunt for extending the wound, because it can endure the structure if it is stopped by beginners. Next one. How to avoid the complication and reused knives are used. Next. The creation of a triplanar incision requires sharp knives. Here we can see how blunt the knives are. In the first slide, there is — in the second one also. The blunt knives, in the lower part, the keratome is so blunt that it will cause so much complications. We’ll show in the video, next one. We have — next one, please. We have recreated a scenario of using the blunt knife in the wet lab. This is the blunt. We can see how much pressure has to be given for creation of this tunnel. But at the end, the entry can happen any time. Also when we use with the blunt tipped keratome, you can see how the viscous membrane is with the blunt knife. There is big chances of viscous membrane. If it is small, it’s undetected. In the next video you can see. Next video. Here this undetected, it’s seen at the end of the surgery. Next one, please. Reused blunt side port knife. It is displacing the whole eyeball. Next one. If you use this reused blade, you can see the margin, at the end, the leaking, it is not healing. Stitches have to be given. Next one, please. Now about capsulorhexis. Next one, please. Some of the few essentials, good visualization is critical for performing each step of the capsulorhexis. Excellent focus is needed. Some need higher magnification. And finding red reflex. Exception is white mature cataract. In image 1, if we can find the reflex by adjusting the head of the patient, it is a good benefit of the capsulorhexis. And other things, essentials are liberal use of OVD. Next one, please. What technique is ideal, is asked by many persons. Each surgeon tries to choose a preferred technique. But more than one technique should be mastered, because of the availability of instruments at different times, and various patient characteristics. Next one. Need to use the capsulary stain. In this case, image 1, it may not be needed, but here it is an excellent necessity. Without it, we cannot proceed. Next one, please. Next one, please. Routine capsulorhexis requires a balance between the forces applied to the anterior capsule by the surgeon against the countertraction force. By deepening the anterior chamber and counteracting the force. Next one, please. We have to — need to understand the vector forces, shearing forces, which is the key. The shearing force is the force applied in the direction of the tear. Start the video, please. The capsular flap is folded like a napkin. Next slide, please. In a nutshell, next one is ripping force. Ripping vector is applied more centrally to redirect the direction of the capsulorhexis. Here in the video we can see high pressure. The surgeon draws it more centrally by the ripping force. If you don’t understand these two forces and don’t apply, we cannot have a good capsulorhexis. Next one, please. For CCC, preferable route, it can be done through any port. Through the main wound, it might require introduction of this over several times. If we can manage it through the cycle, additional elasticity is needed to introduce into the anterior chamber. High positive pressure. Next, please. Double rhexis in case already discussed, past 3 to 4 millimeter diameter, rhexis is done. And then all the milky cortex is taken out by aspiration. The capsule is cut and it is then proceeded with the capsulorhexis forcep. Frequent application of introduction of the OVD is needed at that time also, because lenticular pressure is also not below the average. So there is time to extend. Next one, please. Three more tips. Rhexis margin should be grasped close to the leading edge. Frequent regrasping of the flap every three to four clock hours. Next one, please. The last topic is tips and techniques for prolapsing a pesky nucleus, already described. Next one. Issue of the large nucleus. The large nucleus — video, please. It’s a headache for every surgeon doing rhexis, taking it into the anterior chamber. It isn’t moving, I don’t know why. Then taking — >> PARIKSHIT GOGATE: [Indiscernible] video, sir. >> SARWAR ALAM: Anyway, this is a depiction, it is showing how it is taken out. Next one, please. The wound construction, the size of the wound should not be less than 6.5. The size should be proportionate to the size of the nucleus. Frown incision is good in this type of case. Protection of endothelium by using plenty of OVD and nucleus delivery by sandwich technique. Multiple attempts might be needed. Next one, please. Nucleus delivery by sandwich technique has been already described. I’m showing my cases. Here, you might catch the iris or capsule. Don’t grasp the instruments so firmly until you’re in the middle of the cornea. When in the middle of the cornea, during this moment, if the capsule or the iris is caught, it will be pushed back. Next one, please. Nucleus delivery by multiple attempts. Video, please. Many times, video is not running. Last video. Anyhow, if it is running, I don’t know why — okay. Nucleus delivery by Hennig fish hook technique, from Dr. Hennig of Nepal. Fish hook, after giving plenty of elastic inside, the fish hook is introduced. I don’t know what happened. Fish hook is introduced into the — behind the nucleus of the capsule. Then it is turned up and pulled back so that it is engaged in the central portion of the nucleus. Then it is pulled out. And it is said that the — actually we are not doing this fish hook technique. Next one, please. There are several other techniques. >> PARIKSHIT GOGATE: Summarize in the next two minutes, sir. >> SARWAR ALAM: These techniques are not used because of various complications. Next one, please. So this is the end of my presentation. I’m sorry that I could not run it in my own way. >> PARIKSHIT GOGATE: [Indiscernible] video, sir. >> SARWAR ALAM: We are a teaching institution so we have many videos. Thank you, everyone, for listening patiently. If you have any questions, you can ask. >> PARIKSHIT GOGATE: Thank you. Before we go on to the questions, I think Dr. Nitin’s poll, we could not do that, so if you can just show that and we’ll do that too. >> NITIN TULSYAN: This is the first polling question. So which type of scleral incision causes least astigmatism? I wanted to mention it in my presentation. >> PARIKSHIT GOGATE: I think you covered all the questions, there were questions on what to do with small pupils. >> NITIN TULSYAN: Yes. This is the frown incision, inverted bat wing, and then the smile. And then the next question is how can we manage anterior capsular runout in a case of intumescent white cataract? All three processes are used, so all available, as most of them are the same. That’s all. >> PARIKSHIT GOGATE: Thank you. So I think whatever you taught has been registered bit participants. Since we still have another seven, eight minutes with us, it’s a great question to each one of you. All three of you are also fantastic phaco surgeons. I’ve referred to them so many times. Dr. Nitin, you are also. Each one of you, since this is on manual SICS, we’ll start with Dr. Nitin, where would you have SICS as your technique of choice, even though you would have the best phaco machine next to you? I know you can do both of them equally well. >> NITIN TULSYAN: I didn’t get — in viscouses, doing SICS? >> PARIKSHIT GOGATE: You would feel for the sake of the patient, SICS would be better, or it would be more comfortable to you as a surgeon if you did SICS rather than doing phaco. I know you do phaco in all kinds of cataracts. >> NITIN TULSYAN: Yes. The best thing, I prefer SICS or phaco, one is hypermeasure cataracts and the other is brown and black cataracts, because in that case, if you go for phaco, and we are doing phaco even in brown cataracts, but what happens the next day there is edema and the patient has very less vision, so it’s not satisfactory. It’s better to perform SICS so that he is having clear cornea the next day and has better vision. Similarly, in cases like intumescent cataracts with shallow SC, in those cases, we can go for SICS, phaco can be done, but with some precautions. >> PARIKSHIT GOGATE: Sure. Dr. Haripriya? >> HARIPRIYA ARAVIND: I agree, it’s a safer procedure. Also advanced cataract, with phaco, you’re putting more pressure. If you can manage to make a large enough rhexis or a can opener comfortably, it’s a better technique than doing phaco in those very advanced cases with shaky lens, I think SICS works better. >> PARIKSHIT GOGATE: Dr. Sarwar? >> SARWAR ALAM: Similar to the previous two speakers. If I do phaco, it will exceed 3 millimeters, definitely I go for SICS for sake of corneal surgery. In some of my cases of distrophy, for taking care of the endothelium, because I’m more confident to protect the endothelium with the technique. I prefer in those cases also. >> PARIKSHIT GOGATE: Thank you all of you, you put it very succinctly, to which I will add two more indications. One is in very, very old patients who are 95, 100, whose endothelial counts obviously will not be great, we get some of them in our camps who are not that — again, MSICS can be done. And another indication in India, one doctor has been doing, because it gives a larger astigmatism than phaco, about 1 diopter, he uses SICS if the preoperative astigmatism is 1 or 2 diopters. In many places, lenses are not easily available, or even in our countries, direct lenses are not affordable by everybody, because they are much, much more expensive and we would have to have phaco and a lot of other things that go with them. So there also, SICS can be a very good option. Well, I think that kind of sums it. We still have another five minutes. So thanks to all of you for doing it in time. One other thing which people are very, very scared of is with — with Dr. Nitin, that’s not the case, but we are scared of TC lens, another common question asked from various parts of the world. If we have a — Dr. Nitin? >> NITIN TULSYAN: It’s in the center or occupying more than like one-third, half of the area, how much is the rent? If it’s only the central rent, a very good anterior, we can put the lens in the bag itself. If it’s more than half of the area, then what we do is, we do anterior, very nice anterior so it’s in the AC and replace the lens in the surface. So it all depends, support of the anterior, basically, because sometimes it does help, but it’s not perfect. So if anterior is there, we can have a perfect surgery, in spite of having a rent. >> PARIKSHIT GOGATE: Thank you. Dr. Haripriya. >> HARIPRIYA ARAVIND: The good news is the chance of a nucleus drop is less with phaco. Phaco, with the fluid or pressure is down. So in fact, during phaco, if we have a suspected rent, most surgeons, if we feel lucky, we can work with MSICS. I abandon that incision and go superior, make a nice incision comfortably, prolapse it, and then you can still continue with phaco in those cases, it’s a high chance of nucleus drop. Two complications are common, both rent and zonular dialysis, which is more common in SICS than in phaco. Whichever complication it is, especially with a beginning surgeon, any time you feel something is not right, that question arises in your mind, it’s an indication that things are probably going downhill, so please stop and reassess. If you find you’re able to see the nucleus in the visual axis, it means you probably have a vent. If it is not prolapsed yet. When you have those indications, better to not do a prolapse. You still can have a nucleus drop. But the chances are far lesser. >> PARIKSHIT GOGATE: Dr. Sarwar. >> SARWAR ALAM: Actually I tell all the time my trainees, try to determine the complication so you can manage in a proper way. If it’s directly, we cannot do so many things. And what are the steps? Most importantly is, cortical aspiration. So that measure has to be taken not to take that step. And for SICS, it’s easy to manage than phaco because phaco, if you don’t put attention, it goes on rapidly to more complications. And even when, as Dr. Nitin has said, when it occurs, and the size, depending on that, all the SICS cataract trainee must learn how to do it. So the adequates of putting it in the sulcus is not problematic because we have not committed to the patient that we give that. So these are the things we actually tell the students. >> PARIKSHIT GOGATE: Thank you, sir. Would you also choose certain kinds of cataracts to do SICS initially? >> SARWAR ALAM: To me, sir? >> PARIKSHIT GOGATE: Yes, Dr. Sarwar, sir. >> SARWAR ALAM: Definitely cataracts, we prefer brown cataract, we prefer to do SICS. Another indication is that patient can afford to do phaco. The rural patients, many patients are not able to. So we don’t hesitate to do SICS. In good SICS, the visual is almost similar to phaco. >> PARIKSHIT GOGATE: Dr. Haripriya has a paper in that, 45,000 plus patients with SICS and phaco compared. >> HARIPRIYA ARAVIND: I think complication while learning phaco is definitely more. SICS is probably safer. SICS is a must because they learn the capsulorhexis procedure. With phaco, if you have a problem, doing the horizontal, if you have a problem, if you have the skills in place it is very useful. The astigmatism keeps coming up for all of us. Most of them, not initially, I think initially you would rather go superior, it’s safer. Temporally, you find the limbus is thinner, higher chances of entry. Second, you have a more cylindrical cornea, you may tend to make the wound smaller, the corneal may not be big enough. Because of this, you have dialysis. 300, 400 superior sizes can comfortably migrate, just consciously make the wound larger and the corneal valve has to go well into the cornea, at least 1.5 if not 2 millimeters. That will prevent bleeding from the wound and you will have a good outcome. That is something which we can also consider. >> PARIKSHIT GOGATE: Would you insist that all the trainees, all SICS surgeons also try to do a CCC, a complete capsulorhexis? >> HARIPRIYA ARAVIND: In our training program we do start them off with a capsulorhexis. If they have a problem, of course, we use the cannula, that seems easier than converting them from can opener to a capsulorhexis. The other important reason, like I said, we see this huge difference, and this did better in terms of PCO rates for nine years. That is the power of the square. It’s a design that only works well if you have it in the capsular bag. If somebody can do a rhexis, can opener is fine. Again, brown ones, it’s okay. But 70% of the patients, if they can get this, I think that will be good for most of our patients. >> PARIKSHIT GOGATE: Great, thank you, ma’am. One last question for you, Dr. Tulsyan. Is there an indication where you would say we would not recommend manual MSICS in cataract surgery? It’s open to all three of you. >> HARIPRIYA ARAVIND: I think maybe it’s the patient — >> NITIN TULSYAN: That question — >> HARIPRIYA ARAVIND: Multifocal or something, I think the phaco is better, you have a more predictable outcome. If you want a good outcome, the one thing is, we cannot actually predict the actually astigmatism a wound will induce. I think the phaco is better rather than MSICS. >> SARWAR ALAM: Also maybe patient with chances of bleeding. We can think of that. >> PARIKSHIT GOGATE: Dr. Nitin, if you want to add something, sir. >> NITIN TULSYAN: If a patient has already gone for previous surgeries, glaucoma surgery, we definitely prefer phaco over MSICS. >> PARIKSHIT GOGATE: Thank you. Thank you to all three of you, Professor Sarwar, Professor Haripriya, Professor Tulsyan, you gave your time for this. Thank you to Cybersight, Andy Chen, for making all of this possible. Last but not least, the most important, all our participants from across the globe who gave their time, in some places it’s really very odd hours, but you still came and attended. Thanks a lot, thank you once more. Thank you. With this, we will close the webinar.

Related Resources:

  1. Manual Small Incision Cataract Surgery
  2. Manual: Small Incision Cataract Surgery (Aravind)
  3. Surgery: Manual Small Incision Cataract Surgery (MSICS): The Aravind Way
Last Updated: June 28, 2024

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