Surgery: Tips and Tricks for Safe MSICS: The Aravind Way

This video provides tips and tricks for performing safe manual small incision cataract surgery (MSICS), particularly for novice surgeons. It emphasizes the importance of practicing in a wet lab simulation environment before operating on live patients. The video covers various aspects of MSICS, including the architecture of the scleral corneal tunnel, tunnel construction, capsulorrhexis, nucleus prolapse techniques, nucleus delivery, cortex aspiration, IOL implantation, wound closure, and the overall importance of consistent practice for successful outcomes.

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


Tips and tricks for safe MSICS, the Aravind way. Every budding ophthalmologist understands the importance of learning cataract surgery, either as sutureless extracapsular cataract extraction, or manual small incision cataract surgery, also called MSICS. This video is aimed at giving some of the tips and tricks for performing safe MSICS, especially for novice surgeons. The Arvind MSICS manual offers comprehensive guidance to the trainee in applied anatomy and surgical steps. Alongside the manual. We also encourage our trainees to watch A 2D animated MSICS series on Aurotube. Practicing prior to operating on live patients is of utmost importance. Therefore, we developed a wet lab simulation environment. We created a novel vacuum device for holding the globe and to practice performing scleral tunnels on a cadaver eye or on a silicone sphere. This practice allows for a consistent understanding of proper incision depth and cutting forces, needed for effective tunnel construction.

Architecture of the scleral corneal tunnel is a vital determinant of outcome for MSICS. After conjunctival peri gentle cautery is done and the blue white junction is identified. A frown incision of six to seven millimeters in length, two millimeters from the superior limbus is made. The incision is deepened with the crescent tip. Scleral dissection is done in a wriggling motion and the cornea is entered with the crescent heel down. The rest of the tunnel is dissected through a sweeping out motion. The blade is tilted and rotated to match the contour of the globe while making the side pockets. For the benefit of trainees, we developed a novel device, the MSICS tunnel stamp, to guide the making of a perfect scleral corneal tunnel. The prominent edges are stained with trypan blue and is stamped at the scleral corneal junction with a 1.5 millimeter corneal entry, sufficient side pockets and tunnel length. The device is now made in stainless steel with side handles for easier use and better sterilization.

Tips for safe tunnel construction. The ideal depth of the tunnel is such that the crescent blade is barely visible through sclera. If the blade is very visible, it may be superficial and can lead to buttonholing. If the blade is invisible, it is in a deeper plane and may result in premature entry. Remember, the crescent blade should be heel up during scleral tunnel construction and heel down when entering the cornea, The anterior chamber entry is made, after first creating a side porte entry, staining the anterior capsule with tryan blue and filling the AC with viscoelastic. The globe is gently rotated down to facilitate keratome insertion and pulled back during keratome entry. The keratome should cut while entering the AC and the internal entry is then extended from limbus to limbus. Capsulorrhexis is a crucial step in MSICS. The safe zone for capsulorhexis involves the central six millimeter zonule free area. For advanced cataracts however, a large rhexis is advised. Nucleus prolapse is one of the most challenging steps in MSICS. Several techniques of nucleus prolapse may be employed based on cataract density and all rely on a large enough capsulorhexis for safe prolapse. Hydro prolapse for nuclear sclerosis, grade two to three. The hydro cannula is placed between the capsule and cortex, and the surgeon may gently stretch the capsular margin and then inject the fluid continuously. One pole of the nucleus pops out of the bag and the rest of the nucleus can be gently wheeled out.

Sinskey prolapse for nuclear sclerosis grade three to four. The sinskey is used to hook one end of the equator. The nucleus is gently pushed horizontally to the opposite side, and once the hook side equator is visible, a gentle lifting and rotator movement is done to wheel the nucleus out. Bimanual prolapse for hard and brown black cataracts. Either the cyclodialysis spatula or the hydro cannula and sinskey are used. With the cannula, the rhexis margin is retracted to one side and with the sinskey hook, the nucleus is pushed to the opposite side. Once the equator is visible, the cannula is taken beneath the nucleus and used as a fulcrum, and the rest of the nucleus is lifted and rotated out of the back
Nucleus delivery. Irrigating vectis technique is an ideal technique for all types of cataracts. Viscoelastic should be injected first, above and below the nucleus. The superior rectus bridal suture is held loosely in the left hand. With the concave side up, the irrigating vectis is inserted gently below the nucleus. Do not irrigate saline until the nucleus is engaged in the tunnel. The following three steps should be in synchrony. One, lower lip of the wound depressed. Two ,superior rectus bridal suture is pulled to rotate the globe down, and three, irrigation is started. Cortex aspiration. Before starting cortex aspiration first wash the back of the cornea to make the view clear. Then remove the cortex in each clock hour, the subincisional cortex can be easily approached through the side port. A useful tip is that lifting the anterior lip of the wound with the simcoe cannula helps keep the AC form during cortex aspiration. IOL implantation. A rigid six millimeter PMMA, IOL with a square edge optic is the ideal IOL for implantation. In the capsular bag. Viscoelastic is injected to inflate the bag. Lens holding forceps are used to hold the optic of the IOL. The IOL is gently inserted into the AC pointing downwards with its leading haptic into the bag, the optic is released and the IOL is pushed further into the bag.

The IOL is held at the optic haptic junction and rotated in a clockwise direction. The sinskey is engaged in the dialing hole and the IOL is then pushed to the opposite side, depressed and rotated clockwise into the bag. Viscoelastic is then aspirated from the anterior chamber, followed by wound hydration. While a proper scleral tunnel should self-seal, any wound leakage should be addressed with sutures. The conjunctiva is then closed over the wound, using cautery. MSICS is a valuable cataract surgery technique with excellent visual outcomes, and it should be considered, especially in advanced cataracts. Although it can be performed very quickly by expert surgeons, it is important to be mindful that every step builds on the last. Consistent practice outside of the operating room is key for successful outcomes.

Last Updated: February 28, 2024

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