Surgery: Manual Small Incision Cataract Surgery (MSICS): The Aravind Way

This video describes steps of manual small incision cataract surgery (MSICS), in an eye with dense subcapsular cataract. The surgeon explains the process of creating an incision, dissecting the conjunctival and tenon tissues, cauterizing bleeding points, creating a scleral incision, performing capsullorrhexis and hydrodissection, removing the nucleus, aspirating cortex, inserting the intraocular lens, and closing the scleral tunnel.

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


So you can see this patient having again, a nucleus sclerosis grade two to grade three with a dense subcapsular cataract with a pupil of seven to eight millimeters. A superior rectus bridal suture is done and then the globe is slightly moved down. And then you start your conjunctival and tenon dissection. Roughly you need eight to nine millimeters of clearance. So you undermine under the tenons and then you do one cut, and then the second undermine happens. And then mostly two or three times you can do the conjunctival tenon dissection. It is very important to cauterize the bleeder, especially the bleeding points. So whenever you see a bleeding point, you place the forceps caurtery on top of the bleeding points and make sure the scleral area is clear of blood. Because when you start a tunnel and there is a lot of bleeding there, it makes your scleral tunnel construction difficult, which is very important for the rest of the steps to run smooth. So once you have done a good cautery, make sure your assistant mops that area. And here we are doing a mark of eight millimeters using a caliper and see that dry tissue helps you to make sure you do a good external scleral incision, which is roughly two millimeters from this gray area. And the site will be around three or 3.5 millimeters from the gray area.

And then using a crescent knife, you first reassure the groove made by the 15 blade and then your aim is going to be in the center of the sclera. So once your crescent is barely visible, you are at the right depth. You go into the clear cornea, like if you see the clear cornea is only 0.5 or one millimeters into the clear cornea. And depending on the density of cataract, you make side pockets. Here.,I’m sure the nucleus is not very dense, so we’re making a very small side pocket. So the external groove, if it is eight, the internal one will be nine to 9.5.

And then the side port incision is done for easy access of subincisional cortex. And once that is done, use a 3mm keratome, go right in the center, make a small dimple and then parallel to iris, enter into the anterior chamber. And I do this when you have a normal anterior chamber, which is not pressurized with viscoelastics. And then a little bit of phenocaine is injected for mydriasis. This is followed by staining the anterior capsule. Whenever you stain, it’s good to keep the bubble separate and your blue separate, so that you have a very good control on how much trypan blue you’re using. 0.1 or 0.2 ml is more than enough, repeat the bubble. This repeat helps you to have a very uniform stain and also it stains all your tunnel, your tunnel, your side port. If you have a second side port, everything gets stained because this blue is forced out outside through these tunnels. And then the same keratome is used.

If you see carefully, now we are looking at the external scleral groove here. Now once you are completed the external scleral cut, then you also make sure the pockets are done. So this is very important. You visualize both, so that you have a nice power glass tunnel here. The anterior chamber is again reformed with viscoelastic, and then you pull the globe straight for your capsularrohexis. So you need to have a view like this more straight. So you release your bridal suture and you hold the conjunctiva tenons near the limbus. And then you have this nice exposure for a continuous curvilinear capsularrohexis. Here again, we are touching the pupillary margin with the rhexis because we need a seven millimeter capsularrohexis to prolapse the nucleus safely. So we are almost at the pupillary margin. We are not going beyond it. And then you can see this is again a 27 gauge hydrodissection cannula.

You hydrosdissect at three o’clock and then nine o’clock, three o’clock and nine o’clock. And after some amount of de dissection and delineation, you can see that the one pole is off. So I’m just lifting that pole with the same cannula and then we are going to put viscoelastic under it, to make sure that it is out of the bag. And then using a sinskey hook, you know, the rest of the nucleus can be wheeled. See that you lift the nucleus and then you hold the nucleus with a sinskey hook and then gently wheel the rest of the nucleus from the bag into the anterior chamber. And this is a time you put viscoelastics, especially below the lens. You push the iris capsule diaphragm back. Now I’m zooming down a little bit to see well and then checking the irrigating vectis. The irrigating vectis is now holding onto the nucleus. You press the lip, you start irrigating at this point, when it gets locked, you start irrigating. You can see a deep chamber happening. This is because of the irrigation, and once it is out, you stop the irrigation. If you don’t stop, the lens can jump.

So now you have a very controlled delivery of the nucleus by using this irrigating vectis, where you combine both mechanical and the fluid pressure. And now we are using a simcoe cannula to aspirate the rest of the cortex. So first do it for the inferior cortex like this. Carefully see the capsularrohexis rim, the anterior cortical matter, and then hold the anterior cortical matter and remove it. And whenever you have subincisional, this is a nice way to get rid of the subincisional cortex. Go through the side port so you have a deep chamber and you have a very controlled way of removing. And once this is done, you reform again the chamber with viscoelastic again. See we can see the anterior capsular rim here. So when I’m aiming to put the lens, I would try to go under this anterior capsular rim, the inferior haptics. If it goes under the rim, then we can guarantee, in the bag insertion of intraocular lens. So what I do is when I go, I just touch the PC and then go very gently into the bag. And then with the visco, I push the optic inside the bag. And now using a sinskey hook, you go to the haptic optic junction, move a little bit, and then using a dialing hole, you nudge the lens, the other haptic also into the bag.

And now the Lens is in the capsular bag. The residual visco elastic is washed with the manual irrigation aspiration. And once you have a wash of the viscoelastic, you reform the anterior chamber through the side port and make sure you have a very firm globe. And once you have a firm globe, you remove the bridal suture. And then we need to elegantly close the scleral tunnel, the conjunctival flap over it, by well opposing it with forceps caurtery. And that will be the end of the surgery. Finally, you inject intracameral antibiotic, recheck how firm it is.

Last Updated: March 5, 2024

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