Surgery: Manual Small Incision Cataract Surgery (MSICS): Intracapsular Flipping

This video describes steps of manual small incision cataract surgery (MSICS), in an eye with nucleus sclerosis grade two with posterior subcapsular cataract. The surgeon explains all the normal steps of the MSICS surgery and discusses the step of intracapsular flip, that brings the nucleus into the anterior chamber.

Created by: Dr. Rengaraj Venkatesh, Dr Kannusamy Veena, Dr Shivraj Tagare, Dr. Megha Nair & Dr Kapil Mishara,
Aravind Eye Hospital, Pondicherry


So this is a case of small incision cataract surgery with a patient having nucleus sclerosis grade two with posterior subcapsular cataract. You can see me performing a slightly curvilinear external scleral incision, which is roughly around seven millimeters. And then we are constructing a sclero corneal tunnel. If you see carefully, there are very small side pockets which you need for this particular patient, because the nucleus is not going to be very dense. So after the sclero corneal tunnel, we are performing a side port, and this side port is located so that you can comfortably remove the subincisional cortex later.

I am using a 3 mm keratome, you’re seeing the dimple and then entering and parallel to iris, you enter into the anterior chamber and now a little bit of phenocaine is injected for a good mydriasis. And then the anterior chamber is reformed with viscoelastics. And now the same keratome is used to extend the scleral tunnel. Carefully look at the external scleral tunnel first, and then the internal valve so that we complete both the external and the internal, so that we get something like a hourglass pattern of scleral tunnel, 7 to 7.5, external eight to nine millimeters internal valve. And then again, reform the chamber and see this hole nicely helps you to bring the globe to the center. When you’re doing a capsulorhexis, you need to see and center it nicely so that you can comfortably do a continuous curvilinear capsulorhexis like this.

So ideally you need a six to seven millimeter rhexis which is bigger than what you do for a phaco. And here the pupil is nine millimeters. So we are comfortably doing a seven millimeter continuous curvilinear capsulorhexis. This is followed by a hydro dissection, and the canula, which I’m using is a 26 gauge canula. Now you can see the salinegoing under the lens, and then you do a little bit of delineation, also dissection, followed by delineation. And now you can see one pole of the nucleus out. So what I’m doing here is, using the same dissection cannula to do an intracapsular flip. So this elegantly brings the nucleus into the anterior chamber. And then because the nucleus is small, so small, we are doing an hydro expression using the same cannula. So one single step. Using the hydrodissection, we can do dissection, prolapse and also delivery. And you see there is a lot of epi nucleus and cortex. So finally, a simcoe cannula is used to manually irrigate and aspirate the epi nucleus and cortex. So check the simcoe cannula, check the syringe, and then with a nice flow, you pull the bridal suture.
So that you can express first epi nucleus, and then start removing the inferior cortex. If you carefully see, if you little bit elevate the superior roof of the tunnel, you can get a nice deep chamber, because the rest of the tunnel closes. So this small tip helps you to have a slightly deeper chamber. At the same time, if you feel any pressure in the eye, you have to release the speculum. Also, the speculum should be loosened. The universal speculum, which you use should be loosened, and then the cortex should be aspirated. I think the best way to get to the subincisional cortex is by going through your side port incision, which is carefully constructed to reach the subincisional cortex. Here in this case, it is a little bit of a sticky cortex, but we have loosened the subincisional cortex, and now we are again using an expression to remove some part of it. And further subincisional cortex is. So whenever you’re trying to get into the cortex, it’ll be good to hold the anterior cortical matter. Know, the leaflets, which are so that you don’t hold the posterior cortex, the posterior cortex, when you hold you, there is a high risk for you to damage the posterior capsule.

So this sticky cortex is now left inside, and then viscoelastic is injected into the capsular bag again. And now you can see a nice rhexis and we can implant the lens in the bag. There are a few tips when you do the lens implantation.

It’s good to take the lens by yourself, and then when you are going, make sure the inferior haptic goes into the capsular bag, below the anterior capsular rim. So that’s the key step. Once you have done that, you slightly nudge the optic inside, and now you push the optic. And then using the haptic optic junction, you mightly move. And then using the dialing hole, you nudge the other haptic into the anterior chamber. Here I’m doing a merry-go-round technique because, we left a little bit of cortex in the subincisional area, which is very sticky. And this particular movement helps you to beautifully remove this cortex. It dislodges the cortex from the subincisional area, which can be later washed like this. And then finally the viscoelastic is removed from the anterior chamber. The anterior chamber is reformed, Some loose cortex under the lens is again remote now, and you can see the lens is in the capsular back. So once a thorough wash is done, the AC is reformed. And when you have a tight valve, if you don’t have a tight valve, that means there is some epi nucleus or some cortex, which sometimes it gets locked in the tunnel. So you have to wash the tunnel nicely and then reform the chamber. Like this. If you wash any loose material can get dislodged.

So this you should do whenever you feel the chamber is not forming very well, the globe is not tight enough. And once it’s all done, you remove the bridal suture, pulling the needle part of it outside, and then use a forceps caurtery. This is very important and make this beautiful closure. One or two site burns help you to fuse the conjunctiva to have a nice closure. And finally, you inject intracameral antibiotic moxifloxacin, 0.1 ml to finish the case.

Last Updated: March 12, 2024

3 thoughts on “Surgery: Manual Small Incision Cataract Surgery (MSICS): Intracapsular Flipping”

  1. I Dr choudhury is very much for your support and forward for your program and support this optometry program
    Thanks for your support and forward.


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