Phacoemulsification may be a risky technique of cataract surgery in patients with corneal scar, endothelial diseases and post-keratoplasty scenarios. In all these compromised corneas, MSICS will make the surgery safer, faster and more cornea friendly. This talk will cover the use of modified Blumenthal technique of manual small incision cataract surgery in compromised corneas with the help of step-by-step videos and animations.

Lecturer: Dr. Rishi Swarup, FRCS, Medical Director & Senior Consultant, Swarup Eye Centre, India


Dr. Rishi Swarup: Hello everyone. My name is Dr. Rishi Swarup. I am from Hyderabad, India. I’m an anterior segment surgeon. Although I do a lot of phacoemulsification, I think manual small incision does have its place, and I’m also a cornea specialist. So, I used this quite a bit in my practice. So, I’ll try and share some of my experiences and tips with you. Manual Small Incision Cataract Surgery which is in short called MSICS is a very useful technique of cataract surgery especially for the developing world because of several reasons.

One of the main factors being that it’s a very low cost surgery. It doesn’t need any fancy equipment. It needs simple instruments just like you would for an extracapsular cataract surgery. But the beauty of the surgery is that it just uses an intelligently constructed wound so that you get a self-sealing incision without the need for sutures, and the outcomes are almost comparable to that what you get with the phacoemulsification and in many times even better especially in difficult cataracts.

And one set of difficult cataracts that we all encounter in our clinic is patients having bad corneas, and bad corneas can mean many things. It can mean an opacity which precludes visualization of structures inside the eyes. So, if you can’t see well, you’re likely to make mistakes and have problems during steps of surgery, if you can’t see the capsule or you can’t see the nucleus, you can end up damaging structures that you don’t want to damage. If the cornea has a weak endothelium, we all know that the endothelium does take a beating during cataract surgery, even an uncomplicated simple cataract surgery kills a significant amount of endothelial cells, but we have enough reserve to overcome that damage, iatrogenic damage from surgery.

But if you already have a compromise endothelium like in a Fuchs Endothelial Dystrophy or an elderly patient who’s probably had a viral keratitis or any other reason, such a patient might go into a de-compensation or may have other problems as a consequence of cataract surgery. So, we have to take extra care in these cases. And in my opinion, manual small incision works better than phacoemulsification especially if you have a hard cataract where you will end up using a lot of phacoemulsification energy, manual small incision maybe a lot more friendly to the endothelium.

Irregular corneas like post graft eyes, again scarred eyes, it may be good. Another set of irregular corneas are ectasia, small incision may not be the ideal one for ectasia because it’s already a compromise cornea, you don’t want to make a big incision in a compromised stroma. And post keratoplasty is one major indication wherein my practice I use manual small incision, and I’ll be sharing a couple of videos to demonstrate that. So, when you’re thinking of a cataract surgery in a compromise cornea, there’s no perfect answer that small incision is the way to go. In my hands, small incision works well but if you are prolific phaco surgeon, and the contract is not so dense, phacoemulsification might give you even a better result.

And some people are so well versed with extracapsular that in their hands that we’re better than anything else. So, there’s no strict rule. It really depends upon the surgeon comfort and skill and various other factors like the density of the cataract, how small or big your pupil is and how compliant your iris is going to be, and various other factors like cost, et cetera will also have to be kept in mind.

So, the technique of manual small incision that I have been taught is the Blumenthal technique and that’s the technique that I am very comfortable with, so that I’ll be showing you the Blumenthal technique of manual small incision cataract surgery. I used a modification of that technique. The original technique uses an anterior chamber maintainer but in my experience, I’ve had a few dismiss detachments because of the anterior chamber maintenance, so I’ve stopped using it and I used a modification of that technique without the anterior chamber maintainer, I’ll show you that in a video.

So, this is a patient who’s got an advanced pterygium with a scar and a cataract. One of the first steps is to create a phonic space, you can see this advanced ptergyium, it’s coming into the visual axis. Normally, we would do a conjunctiva table incision first but in this case because there’s an advanced pterygium, we would excise the pterygium like so. I like to take the epithelium of the graph first and then excise the sub-epithelial fiber vascular tissue that’s been cleaned and we’ve got [indiscernible] [00:05:19] bleeders. Now, we’re harvesting the graph from the superior Bulbar conjunctiva. I usually don’t take the limbus I just take the conjunctival graph. In this case, we’ve got a little bit of thinner but otherwise, you like to take as thin a graft as possible, so Fibrin glue being applied on the bed, and then you basically put your graft in place and either saturate or you can just take it down.

So, basically you complete the entire pterygium surgery first and the conjunctiva table incision that you have made superiorly can then be used like your Peritomy which you would normally do for your scleral tunnels. So cauterize the big bleeders, reflect the tenons, make your incision in this case where a little closer to the limbus about one millimeter behind, you can make it, make out, it’s a 50% depth. So, how do you make it out that is 50%, you start seeing a little bit of gray or blue and then you make these back cuts, so, it’s 5.5 millimeters or 5 or 5.5 millimeters straight with two millimeters back cuts and then grip these scleral behind with the tooth forceps and then use a crescent blade to make your tunnel.

It’s important to make the blade flat on this sclera like so and keep the heel down when you’re doing the dissections. Side ports, 90 degrees across, I like to make two side ports. I’m doing the capsular axis. One could also do the capsular axis as the first step. It’s a good idea to use trypan blue. In this case because the visibility is so poor, I chose to do a can opener, also because it’s a very big cataract. But when I really want to do a capsular axis whenever possible.

And then after a hydrodissection, you basically try and prolapse the nucleus out of the capsular bag. In this case I’m using a Sinskey Hook, one could also use a cannula to prolapse it. It’s important to take out 50% of the nucleus out of the pupil and the capsular bag and once that is done you can just depress the wound with a McPherson’s Forceps, giving counter pressure at 6 o’clock and then you can, but if sometimes the nucleus get stuck in the wound, then you can use two instruments to just kind of rotated out of the eye, and that’s done.

You can see it’s a massive nucleus. And even though the scar is almost in the pupillary axis, we were able to do a fairly safe cataract surgery using a bi-manual now to remove the cortex. Now, this pupil when it comes down, it’s going to come to the edge of the scar and I don’t want that. I want the patient to be able to see from that clear area here, so after putting in the lens, what I’m going to do is, I’m going to enlarge the pupil on this edge a little bit so that he’ll have a window through which you he can see. So, the lens has gone in, and now you can see I’m using a Venus to just make this little sphincterotomy only on the nasal side, on the temporal side so that there will be a window through which the patient can see and actually this patient did pretty heal. He got 20/30 vision and he was pretty happy and we didn’t have to do anything for the scar.

So, once this is done, you basically opposed the superior Bulbar conjunctiva and closed the eye, because it’s a scarred cornea, sometimes the port may not hold on hydration and may be necessary to put a suture, but in this case we didn’t have to put a suture, and it’s done quite well. So, the commonest thing that we encounter is an opacity. And traditionally, we’ve been taught that corneal opacity are, sorry classified as nebula, macula and leukoma, depending on the density of the opacity but it’s not as simple as that. In addition to the density of the opacity other things which have to be kept in mind is the size or extent of the opacity and also the location with respect to the center of the cornea or the pupil rear or the visual access.

So, this is the decision tree that I follow. If it’s, if I’m just thinking of manual small incision of course I do phacoemulsification also sometimes but in this talk I’m going to be focusing on small incision. So, if it’s an eccentric scar, one could just get away with a manual small incision cataract surgery alone because it’s really not going to disturb your visualization and you should be able to complete the surgery quite easily. But if it’s a scar that’s coming into your pupillary axis or it’s going to be disturbing your visualization during surgery, then you have to do well, in addition to your routine steps of small incision, you also have to do some special steps and I like to call that MSICS plus.

And if it’s a dense scar which is right in the center and it’s really going to not allow the patient to see after surgery. And even you also it is going to be very, very compromised then you may have to do keratoplasty along with the cataract surgery, you could combine it with a small incision, you could combine it with the phacoemulsification. You could even do an open-sky and this is called a triple procedure. So, when I’m saying MSICS plus, there are various manuals that you can do to improve your visualization during cataract surgery. And one of the simplest things to do is put viscoelastic on the cornea especially if you have a very regular surface putting a dispersal viscoelastic like so, in this case I’ve used HPMC suddenly improves your visualization quite a bit.

And then the on your right, you can see a video of Endoilluminator being used. Endoilluminator I think a fantastic tool which all of us should have in our clinic. It’s not very expensive. The [indiscernible] [00:11:29] colleagues use it all the time for doing the VR surgeries, but you do get standalone Endoilluminator which is basically a light source connected to a fiber optic cable and that can be then put either on the surface of the eye tangentially or obliquely or it can also be put into the eye through a side port, And that significantly improves your visualization of structures inside the eye, be it the membrane or the iris or the pupil or the capsule or the nuclear material or cortical material, so if you have a capsular dehiscence, zonular dehiscence all of that can be seen very well when the view is not so great. So, I would urge all of you to have an Endoilluminator. It’s like a magic wand when you can’t see. It will show you what you can’t see.

If your surface is unhealthy, the epithelium is unhealthy or you have these kind of deposits, the video on the top shows Salzmann’s nodular degeneration and some scarring, and the video below is a case of gelatinous like keratoplasty, the patient has a deep lamellar keratoplasty, but again the surface has become unhealthy, so this patient is going for a cataract surgery, so we can easily debride the surface. And that can sometimes cause a significant improvement in your visualization. Of course at the end of surgery, you will have to put a bandage contact lens or add some other procedure like an amniotic membrane graft to aid the apathy healing. But more important thing when you’re doing cataract surgery is that you do a safe cataract surgery without compromising the capsule. And to that end, if you need to take off the epithelium, so be it.

The second important entity that we all encounter in our clinics is a compromised endothelium, now this can be a spectrum ranging from guttate changes, otherwise the corner is clear to advance bullous keratopathy like you’re seeing in this picture. And midway is just a stromal edema without epithelial edema. So, till the stage of stromal edema, you can actually have pretty good vision, and the cornea may not really compromise your visual outcome.

But if you have stromal edema, it means that the endothelium is not really working. And such patients, sometimes it may be wise to primarily think of keratoplasty or at least warn the patients that you will be needing a keratoplasty soon. So, this is the algorithm that I follow. You know, one could do a speculum microscopy and look at the count, but I don’t think that helps me take a decision about whether I must primarily do a keratoplasty or just a cataract surgery. There are patients with very low endothelium counts, even as low as 500 who continue to have very clear corneas and will not end up in any compensation.

But the real thing that you have to see is clinical edema. So, if you’re actually having only guttage changes and no edema, then one could actually just go ahead with a careful manual small incision cataract surgery with explained prognosis, of course. But if you’re seeing mild edema on the slit-lamp and how does one make out, you will initially only see stromal edema before you see epithelial edema when you were in the endothelium as weak. And if you’re just seeing stromal edema, how do you make it out? The simplest ways to look at the slit of the stromal, normal corneas, the central stroma is thinner than the peripheral stroma.

But if you’ve got stromal edema, the center can be equal to or even thicker than the peripheral cornea, and that can give you an indication that this cornea is swollen. So, and that, once it crosses a certain degree of thickness, my cut off is 650 microns, it may be a good idea to think of primarily endothelial keratoplasty along with the cataract surgery. Of course, once you have epithelial edema and bullous changes, there’s really nothing to think about, you would straight away go ahead and perform a triple procedure.

Now in the second category of stromal edema without epithelial edema or even the first category, one of the useful ways is to ask the patient for history of morning blurring of vision. Many of these patients, the first symptom they have is blurring of vision in the mornings after a full night’s sleep, the stroma swells up because the eyelid is covering and preventing heat resistanceof the stroma. And if they’re having the symptom, then it’s very likely that this cornea is not really going to hold the trauma of cataract surgery and it may be a good idea to think of a triple procedure primarily.

Another entity where you come across an endothelial, a compromise endothelium or a pressured endothelium as a post-graft situation especially a post penetrating keratoplasty. So, we have to take certain precautions like to protect the endothelium, entered outside the graft, so make your entry into the anterior chamber outside the graft. It’s not always possible but when it’s possible you should do that. Use a soft shell technique, which is basically a combination of a dispersive first and then a cohesive viscoelastic inside. So, a shell of dispersive with a cohesive cushion inside and that gives you both the functions of protecting the structures of the anterior chamber and the endothelium, and also keeping the anterior chamber formed.

Respect the endothelium while touching it, keep injecting repeated viscoelastic. You have to choose your lens carefully. Avoid premium lenses like multi-focal, avoid acrylic, hydrophobic acrylic lenses. Hydrophilic acrylic lenses because if you’re going to be doing an endothelium keratoplasty, you need to put in air, and this can cause calcification of the lens material. Lens powers will also have to be selected with special considerations because these are irregular corneas, and so you will have to look in to the keratometry for lens calculation.

Sometimes you have to do a triple procedure in these cases and a good thing to do is endothelium keratoplasty alone. Endothelium keratoplasty is now pretty much given up unless you also have a stromal pathology. So, if you got an isolated endothelial problem with a cataract, best would be to do an endothelium keratolasty like either a DSAEK, or a DMEK. If you’re going to be doing a DMEK, manual small incision is probably not the ideal cataract surgery,, you would want to do as small an incision as possible, so in such cases it’s probably a good idea to do a phaco, along with the DMEK, or if you’re doing a DMEK, then you could make a separate incision for introducing the graft and then suture up the small incision wound after the cataract surgery stand.

So, this is just a series of videos to show a case with the hard cataract who had a Fuchs’ endothelial dystrophy, so you can see already the incision has been made and it’s the Blumenthal incision is a 5.5 millimeters straight cut with two back cuts, like as seen here. It’s a 50% depth wound, the straight cut is about two millimeters behind the limbus, 1.5 to 2 millimeters and then these are about 1.5 millimeters the back cut, angle it back cuts. So, it’s something like a frown, like a sharp frown. Once you’ve done this then you initiate your dissection with a sterile tunnel and then you make an anterior chamber entry. I’ll show you those steps later in a more detailed video.

And in this case, the axis has been done, and the nucleus is being prolapsed here using a Sinskey Hook and then using pressure, counter pressure under the viscoelastic, you can express the new place quite easily. Any size of nucleus can be removed to a Blumenthal incision in my experience. You just need to construct your wound properly and you don’t need to bisect the nucleus. You don’t need to bring the entire nucleus into the anterior chamber. It comes straight out of the bag. Only the superior prolapse into the anterior chamber then out of the eye.

And then of course, you can use several techniques to remove the cortex. One could use a single port cannula with the 90 chamber maintainer. In this case I’m using a bi-manual irrigation aspiration from my phacoemulsification unit. You could also use a Simcoe. After you put in the lens and wash the viscoelastic you introduce the endothelial graft like so. In this case, we’re using a intraocular forceps to drag the graft in, and then you just inflict the anterior chamber with balanced salt solution and put air in the anterior chamber to [indiscernible] [00:30:38] the graft against this stroma.

So, the important thing to remember here is that the IOL power has to be selected carefree depending on the procedure of endothelial keratoplasty. For doing a DMEK, you can choose an emmetropic power. But if you’re using a DSAEK, then it would be better to go for a slightly myopic graft because the DSAEK lenticule causes a slight hyperopic shift about 1 to 1.5 diopters. And like I mentioned earlier, avoid using hydraulic acrylic lenses because there is a risk of calcification and that can compromise your visual outcome.

So, having a pterygium is like a chicken versus egg situation. When you have a pterygium with a cataract, you don’t know which one to do first or whether you should do it together so that my decision tree is like this. It depends upon the size and activity of the pterygium and how much it is distorting the cornea. If it is a small atrophic pterygium which is not likely to progress and it’s not in the pupil recess, I will just go ahead with the routine cataract surgery, and just implant the lens as usual.

One of the useful tools is to look at the topography which will tell you if the pterygium is having any topographic effect and whether it’s causing any distortion. And if the topography is pretty okay in the center, then just go ahead and do just a cataract surgery. If it is distorting the central cornea, it’s always a good idea to remove the pterygium. Ideally, the pterygium should be removed first and then after a gap of two to three months only, one must do the cataract surgery. So, if it’s an active fleshy pterygium like so, then there’s really no choice, you have to take of this pterygium first, wait for the cornea to settle down which takes up to three months and only then go ahead and plan your cataracts surgery with lengths. The reason one has to wait for three months is because the stroma keeps remodeling after three months, so you especially, if you want to put Toric lens later, it’s important to wait for the corneal astigmatism to stabilize.

Yes, so the next important situation is cataract surgery in the setting off keratoplasty, and what this could be after an endothelium graft or after penetrating keratoplasty or a deep lamellar keratoplasty. All these situations, the endothelium is precious and one has to respect the endothelium. So once again, use the technique which works best in your hands. Anything which is going to cause minimal endothelium injury, considering your comfort level with the particular technique, the hardness of the cataract, and the working space in the anterior chamber.

Again, for me, my go to technique in many of these cases is small incision cataract surgery. So, in this case again, we’ve made the incision and we’re just making the anterior chamber entry. The reason we had to do, normally, I would wait for all the sutures to be out and the corneal astigmatism to stabilize before doing a cataract surgery. But this case, the cataract was intermittent and the anterior chamber is getting very shallow and the intraocular pressure was going up. So, there was an urgency to do cataract surgery soon and that’s what we’re doing in this case. So we’ve made the anterior chamber entry and the capsular axis, et cetera has been done and we’re just going to now and then you can see after that the after decompressing, the lens anterior chamber formed quite nicely and we’re using a Sinskey Hook to again prolapse the nucleus out.

I like to use the Sinskey Hook in advanced cataracts. It’s a lot more control in my hands and often I like to go through the main wound. And with this gentle maneuver, I try to prolapse half the nucleus out or more than half and once that is done you can see no where they, can a lenses touching the endothelium. It’s just sitting on the iris. You give counter pressure at 6 o’clock like so and then put a McPherson into the wound to press the internal lid and pressure counter pressure and very gently a nucleus is out as you can see here.

The lens like I told you earlier also it can, the calculation can be challenging. TORIC IOLs can be used but they have to be used with caution. You have to make sure that the astigmatism is largely regular, otherwise you can end up with an unhappy patient with a lot of photic phenomena, a wide multi-focal and tri-focal and extended up the focal lenses in these patients, they will not be happy. And, like again avoid hydrophilic acrylic lenses. So, this is just an example of a patient who have a TORIC IOL and seven diopter cornea astigmatism was neutralized very beautifully.

I’m just going to show you one video before we conclude. So, this was a patient who has had a deep lamellar keratoplasty and had quite an advanced cataracts. So, we chose to do a manual small incision cataract surgery, so you can see we need to sterile the tunnel. We’re making the sterile tunnel. We’ve done a Blumenthal incision which is about one millimeter behind the limbus straight cut with back cuts. You could see the heal of the crescent blade is always sitting on this clear. That’s very important so that your sterile tunnel is always in the same plane as the globe. Otherwise, if your heal is up, you can have a premature entry. It’s important that your sides of your tunnel, the pockets are created well, otherwise if you have a big nucleus, it will get stuck in the wound. So, the side, the section is very, very important.

In this case, we’re doing temporal incision because the patient had a lot of against the rule astigmatism, side port has been created, viscoelastic has been introduced into the anterior chamber and we’re creating a Rex’s now which is done with the needle. It’s important to get a large Rex’s when you’re doing a manual small incision cataract surgery unlike your phaco where a 5 or 5.5 millimeter Rex’s is good enough, especially if you have a big nucleus, you need a big Rex’s, otherwise you’re going to end up compromising your zonulars.

After you’ve created the other side port, then you can have your entering to the anterior chamber. I like to use a keratome directly. This is a 2.8 keratome, so you enter, once you enter horizontalized your keratome, parallel to the iris and cut on the down stroke. Don’t cut while withdrawing the blade ideally, so that your internal lid is parallel to the limbus. And make sure that your internal lid joins up the limbus on both sides. It’s ideal to have a 8 or 8.5 millimeter internal lid and through that almost any size of nucleus will come out quite comfortable.

Hydrodissection is important to free the nucleus, so you can rotate it a little bit. Sometimes you can even prolapse the nucleus out just with hydro dissection, that’s called hydro prolapse. In this case again, I like to use the Sinskey Hook, so I put with viscoelastic and I’m rotating the nucleus out. You can see I’ve got a poll and then again going in through the main wound and prolapsing the rest of the pullout and then pressure counter pressure like I showed you earlier. Sometimes, a big nucleus can get stuck especially if you’re dissection is of optimal. But if you’ve got the nuclear stuck then more often than not it will come out. You just need to manipulate it a little bit. In this case I’m using a Sinskey Hook. Don’t just pull. You have to rotate the nucleus out like the old style telephone, you have to dial it out, and there you go.

I’m sorry the video is not very well centered. That’s actually out now. And once that is done you can again depress the, you see it’s a massive dark nucleus. You can depress the wound again to remove the epi-nucleus and a lot of the cortical material. I like to use the bi-manual irrigation aspiration but if you don’t have it you could use the Simcoe as well, you can just enlarge the side port a little bit. You could use a single port cannula mounted on our syringe and have an anterior chamber maintainer through the other side port.

It’s important to always keep your port up and because it’s about bi-manual kind of a system the anterior chamber is better formed with lesser prolapse. If you’re using the Simcoe through the main wound then anterior chamber tends to collapse and you can end up damaging the capsule sometimes. In this case, we’re introducing a three piece lens into the back causing quite comfortably like so, just making sure that the lens is well in the back. And once that is done you just need to check your – remove the viscoelastic again using the bi-manual for that. And then you basically hydrate your side ports, check the integrity of your main wound, right with a Merocel sponge or cotton-tipped applicator, make sure there’s no leak. And once that is done, if you feel the need to put suture, you must, especially in a post-keratoplasty situation, the wounds can sometimes leak, so it may not be a bad idea to suture up this wounds, wounds which is what I’m doing in this particular case as you can see here. And after that you basically just need to cauterize the conjunctiva and close it, one could also close the conjunctiva with sutures if you like.

So, you can see the cornea is pristine and not being touched at all. And I’m sure if I had done a phacoemulsification in this situation, I would have caused a lot more damage to this endothelium than this gently manual small incision cataract surgery has done. And I’ve done so many of these and these patients do really well, that’s my go to technique when I’m doing a post-craft cataract surgery, especially if the cataract is hard.

So, to conclude cataract surgery in corneal diseases pose many challenges, IOL, with respect to IOL calculation, selection, intra-op visualization is a major problem and because of that you may have a propensity to complications. Using an endo-illuminator, use of trypan blue, use of viscoelastic on the surface helps to improve your visualization, removing the epithelium debridement, all these maneuvers can help you with different steps of cataract surgery. Manual Small Incision cataract surgery provides a safe and cheap alternative to phacoemulsification in these compromised corneas and difficult eyes, both to improve your visualization and also to protect the endothelium. Thank you.

How important is scleral thickness? Do you deal with thin sclera? If you are thinking of doing a manual of small incision cataract surgery, it’s important to have a normal sclera. If you have a patient with the thin sclera, post scleritis, etcetera, it’s always better to avoid going through this sclera, either a limbal wound or a clear corneal incision would be best in such cases. So, yes don’t do manual small incision in these cases if it’s possible.

What is the best OVD for a compromise cornea? Ideally, one could use a soft shell technique or you could use visco-adaptive kind of OVD which will provide both formation of the anterior chamber space and prediction of the endothelium and anterior chamber structures. So, a combination of cohesive and dispersive or of visco-adaptive like viscoit.

When to use an endo-illuminator? Endo-illuminator is a fabulous instrument, like I said earlier. You don’t need to use it when you can see well. But if you can’t see well because of any reason or because you’re saying because you have a decimate detachment or posterior capsular the essence of [indiscernible] [00:32:40] which is not clearly seen sometimes. In all these situations an endo-illuminator is useful especially if you have poor visualization because of a corneal opacity.

If you have a dense grade four cataract with the low specular count, what should we do? I think I told you my algorithm. If you have a low count and a dense cataract, this is a recipe for disaster. And if you’re well verse with small incision or even if with extra capsular cataract surgery, I think that maybe a wiser alternative than phacoemulsification very often. I’m not saying that phacoemulsification cannot be done. It can be done and we can get wonderful outcomes also. So, it really depends on your comfort level, the kind of machine that you have and how dense the cataract is, how bad your pupil is, how likely your — to use a lot of phaco energy during the surgery.

If it’s a combined cataract and glaucoma surgery? So yes, so you can combine manual small incision with glaucoma surgery. In fact it’s very, very easy with manual small incision because you already have a large wound, and so you can easily create your trabeculectomy along with that. And that’s a triple procedure and it’s pretty simple, just like you would do with the phacoemulsification, you can do it with a small incision and it’s pretty easy.

So, manual small incision in post LASIK and C3RIs, which is cross linked eyes, I think it’s probably not a great idea to do a small incision in eyes which are thin, have a thin cornea, if possible do a phacoemulsification because you want to create as small incision as possible that to — try to go into an area which doesn’t have thinning. So, if you have a peripheral ectasia like a pellucid, try to go in from an area which is relatively normal in thickness and preferably do a skill tunnel rather than a clear condensation for your phacoemulsification.

Can tilting the patients head overcome corneal opacity? Yes, to some extent, tilting the eye or the patient’s head can sometimes help you see a little better but only to a certain extent. And if it’s too bad then you have to make use of other maneuvers to improve your visualization.

Penetrating keratoplasty with IOL, should we be doing in the same sitting or separate? I always like to do my cataract surgery separate from penetrating keratoplasty. But sometimes it’s necessary to do it together, and that’s also okay. Whether to use a cohesive or dispersive viscoelastic, if you’re going to be anyway, removing the cornea, it doesn’t really matter so much. But cohesive will keep your anterior chamber formed a little better. So, if you have risk of shallow anterior chamber or capsule being weak, et cetera, so you could want to have a better formed anterior chamber by using a cohesive viscoelastic.

If there is bullous keratoplasty, how to proceed, I think if you, once you reach a stage of bullous keratoplasty, doing just a cataracts surgery is not going to help, you will have to combine it with some sort of an endothelium keratoplasty or a penetrating keratoplasty if you don’t have the skill or the option to do endothelium keratoplasty.

What is the best technique for nucleus delivery in weak corneas? In my hands, the Blumenthal technique works really well. Something else may work well in your hands as well. Basic principle is any technique where which will minimize the chance of an anterior chamber manipulation, minimize chance of endothelial touch is the best technique. I like the Blumenthal technique because there is no question of introducing a lot of instruments into the anterior chamber, you’re not bisecting the nucleus, you’re not putting a large vectus inside the eye. Most of the manipulations are done outside the eye, so, the chance of the endothelium of being touched by the nucleus is much less in this technique in my hands, and the whole nucleus doesn’t come into the anterior chamber, only the superior prolapse is out and that directly comes out of the eye when you depress the wound. So, that is better.

I touched upon the role of speculum microscopy. It does definitely helps you prognosticate but it doesn’t help me take my clinical decision of whether I want to combine it with the keratoplasty. So, it’s good to have and good to follow but I think pachymetry is more useful than Specular microscopy.

How to view capsule and anterior chambers structure during surgery? I think endothelium is the best thing and the other maneuvers like removing the epithelium, putting with viscoelastic, et cetera, like we discussed. MSICS versus Phaco in bad corneas, I think I told you this. It depends on what you’re comfortable with, how bad the cataracts is, how bad the pupil is, how bad visualization is, depending on all of these you have to take a calculated decision.

How to prevent Descemet’s detachment during small incision? I use sharp instruments and I’d like to avoid using the anterior chamber maintainer because sometimes it can slip out. And if it slips out and you don’t notice it, the fluid from the anterior chamber maintainer can detached the Descemet. People with compromised endothelium and guttage changes are the ones who have a lot more Descemet detachment, so in these patients you have to be a lot more careful and keep an eye on the Descemet. If you have any doubt, Tamponade with the large air bubble at the end of surgery.

Management of postoperative astigmatism, one of the problems with small incision is it causes a lot more astigmatism than fake normal certification. So, one of the things you can do to mitigate that is make your incision on the steep access. But if you do end up with a lot of astigmatism, there are ways of tackling that. You could do, you could do limbal relaxing incision or Astigmatic Keratotomy, you could do, if you have access to an eczema, you could corrected using topographic guided ablation. And of course you could do a piggyback toric lens if you have a lot off residual astigmatism and that can correct larger amount of astigmatism but wonderful results.

Which incision is better Frown of Blumenthal, I don’t think the incision matters so much. Both would work really well. As long as your incision is the tunnel is big enough, it doesn’t really matter. Even Blumenthal technique is very similar to a Frown. What is this soft shell technique, we discuss that. You have first viscoelastic cushion which codes the antizymes structure and said that you have bullets off cohesive. And so, first it disperses you and then a cohesive with viscoelastic bullets inside that.

Thank you. So, there’s a question. What will you do if you puncture or penetrate the cornea while doing keratoplasty. If you damage or puncture while suture, you will just suture it up. That’s all you need to do. You’re anyway doing keratoplasty, so it’s okay. You can switch it up that area a little better. It’s okay to put a few extra sutures if you feel that it is sneaking.

Dr. Swarup, do you use liberal steroids in eyes with Manual Small Incision Cataract Surgery with epithelial debridement with superficial deposits which remove during Cataract surgery? So, I think the question is if you’re removing the epithelium, is it okay to use steroids? Yes, it’s okay. You, of course have to give prophylactic antibiotics. But it’s perfectly all right to give steroids as well. Just keep a close watch. Maybe you don’t want to give very frequency rights but it’s okay to give them.

What is the rational against the use of hydrophilic IOL and compromise epithelium? Basically the rational is if you’re going to be doing e endothelial keratoplasty like a DSEK or DMEK, you have to leave air bubble in the anterior chamber for some period of time. And studies have shown that if you leave anterior chamber air which is in contact with the hydrophilic acrylic material for a longer period, it causes calcification of the material and that can cause — that can severely affect the visual performance of the IOL. So, if you’re thinking that you might require an endothelial graph, better to put a hydrophobic material rather than a hydrophilic acrylic material.

What is the price of Endo-illuminator and which company are mean source to buy? It really depends on which geographical location you’re in. In India, there are a lot of Indian companies which make the Endo-illuminator box with which a regular probe can be attached. And I think in Indian rupees, it costs about ₹15 to ₹20,000. So, it’s not very expensive as much as premium lens will cost you.

Why you name MSICS place keratoplasty as triple procedure, we should be calling a double procedure? It’s triple because cataract extraction plus lens plus keratoplasty. Even if you are combining a trabeculate to meets collectible procedure. So, when the third procedure is the lens implantation. Regarding incision, there are several variants like Frown, straight and the one you have shown which is the preferred one in terms of less post-operative astigmatism. I think Frown or the Blumenthal will have lesser than straight. I think Cock had this wonderful postulate which he showed that the Frown style of incision induces less astigmatism. But I’m not really sure if that has been proven clinically.

Can we use a can opener capsulotomy if MSI, in MSICS if capsulorhexis difficult? Yes, I showed you one video in which I have done that as well. But just be careful that you’re, if you’re using a can opener sometimes, your risk the capsulotomy frayed edges can communicate to the posterior capsule and that can cause problems. So, just be careful in your maneuvers if you have, if you don’t have a true bag which means you don’t have a capsulorhexis.

Some cases have a high astigmatism, why? So, the more you go into the cornea the higher will be your astigmatism. And of course a larger incision will introduce, induce a larger amount of astigmatism and the incision is certainly larger in a manual small incision. My own hands, I induce about 1.5 to 1.75 diopter off astigmatism with my Blumenthal incision. And sometimes I use it to my advantage if I have highest astigmatism. So, if you have a lot of astigmatism and the patient cannot afford Toric IOL, you can actually sometimes just do a small incision and that might help you.

If the K1and K2 is not cleared due to astigmatism, sorry, what is the most appropriate size site and shape of the incision? Basically you have to be in this kera, 1 1millimeter or 1.5 millimeter behind the limbus. And superior incision is preferable in my opinion because after the surgery your incision is covered by the lid and because it’s a larger incision, it’s always better that it’s not exposed. But the disadvantage of that is it will also induce more astigmatism compared to a temporal location. So, you have to take into account all the factors and take a decision. Shape of incision, we have already discussed.

If the K1 and K2 is not cleared due to astigmatism, can we take the other I values? Not ideal, but yes if you don’t have an option, that’s something which can be done. If you’re going to be removing the cornea with the keratoplasty, it doesn’t really matter. You can also go with the standard keratometry of 44 nectors. Why do you make to side ports? Because I used by manual to do my irrigation aspiration. Otherwise, you could, if you’re just doing simple aspiration you could make one.

How to do biometric in cases with corneal dystrophy, large terrorism and Leucoma? So, if you have a very regular cornea like we just discussed, you can go with the keratometry of the fellow eye. Otherwise, you can take the help of some advanced instrumentation, some newer optical biometers, topographic instruments or city assisted keratometric also be taken. So, various things are possible but it’s sometimes just a guess and you may end up with the effect of surprise.

Without anterior chamber maintainer, can we call this blumenthalic? Yes, it’s a modified Blumenthal. The Blumenthal technique is the incision. It’s the Blumenthal incision. Your method of choice to control IOP, in your case of intumescent cataract post keratoplasty, most of the time, once the nucleus the cataract is out, the IOP will come under control. But if it doesn’t then you need to look at the angles to see if they have synechia and then you’ll have to manage it appropriately with medication or surgical treatment as is appropriate. Initially of course, you have to give a topical antiglaucoma medication and also manage all before the surgery.

You calculate the corneal endothelial cell density before and after surgery? Yes, it’s a good idea to look at the cell density to see how much damage your surgery has caused. Especially, endothelium has been weak. But like I told you earlier it doesn’t really decide what technique would use, or what that I’m going to do a triple procedure or just a cataract surgery. It may help decide on choosing a small incision over a phacoemulsification, if I find the endothelium is not so great.

What are your thoughts on small incision done temporary? It’s perfectly fine. It works well but I like to do it superiorly because I like the wound covered by the islet. Do you conduct hands on courses for keratoplasty if a phacoemulsification or small incision? I don’t routinely conduct hands on. But if somebody is interested in coming for training I’ll be happy to help them and they can contact me directly. What do you, what you do if you notice the wound is too small? How do you enlarge this type of wound? If your incision is small and the nucleus is not coming out, I would push the nucleus back into the anterior chamber, put a good amount of viscoelastic as a cushion, enlarge the wound a little more using a keratome or an extension blade, go a little into the sclera on both sides and then try again. And again, if the nucleus gets stuck sometimes just maneuvering it out using a second instrument like a Sinskey Hook or even a cystotome helps to just engage the nucleus and then you dial it out. It’s a good idea if you have a good assistant who can help you with that as well because your hands will be busy giving pressure and counter pressure.

What is the preferred IOL PMMA for liberal or three-piece? Really, any lens could be used if you’re having three-piece hydrophobic material that would be ideal if you have an intact capsulorhexis that should only go into the back. If you’re not sure about your excess, if you have can opener then please go ahead and use the PMMA also if you like. It’s not a good idea to put a foldable lens in the sulcus, you should ideally be putting these inside the bag. So, if you can put it in the bag, maturity then use foldable lens otherwise go ahead and put a rigid lens, it’s perfectly okay.

Interest of the anterior chamber maintainer, yes, I used to be using it quite a bit. You could use it if you’re comfortable. But in my hands I don’t really find the need for it. I managing quite well in the technique that I’m doing. Do you do hydro dissection with can opener technique? Yes, but it has to be gentle. Don’t do a vigorous hydro dissection. How to avoid facing this cleaner through the wound? Normally, switching afterwards or with diathermy, don’t you fear I will miscalculation with Pteryguim on the other hand why wait to two to three months after the moving to Pteryguim?

Okay, so first question, how to avoid facing this clearer through the wound? If you’re not sure about the depth to the incision into three steps, don’t go hard on your initial incision. Make a gentle stroke. Then see if you’re seeing a bit of grey. If you’re not you can deepen that cut. And once you start seeing a little bit of grey that means you read about 50% thickness and then you can make the rest of the incision at that depth. If you go too hard, you may end up with a very deep wound and you could have a premature entry.

Do you, don’t you fear I will miscalculation with Pteryguim? Yes, and that’s the reason I like to do the Pteryguim surgery first and then wait two to three months for the cornea shape to stabilize. I’ve burned my fingers by doing the cataract surgery earlier. Cornea shape will keep changing for two to three months. Especially if you’re thinking of putting a toric lens, I would certainly wait two/three months because the IOL induce cylinder cannot be corrected at corneal even a contact lens will not corrected.

Do you give more details about — can you give more details about wound construction? So, I think I described that in detailed. You want to make the Blumenthal technique, you make a straight cut with two back cuts. And these back cut are in 90 degrees, there are about 210 degrees. The straight cut is about 5 or 5.5 millimeters. It’s a 1 to 1.5 millimeters behind the limbus. And the back cuts further 1.5 to 2 millimeters behind from the edge of a straight cut. And you want to then use this crescent blade at 50% depth all around the straight cut till you extend about one millimeter into the cornea.

If, and the side pocket should also be made well otherwise a large nucleus will not come out. Once you’ve done the dissection throughout, the internal lips should be about 8 to 8.5 millimeters for a large nucleus. Then you go in with your sharp keratome. Lift your heel off your karetome so that you create a dimple, enter into the anterior chamber. As soon as you enter, horizontal is your keratome and then cut on down stroke to extend your internal lip on both sides till you reach the limbus. And that’s how you make the wound construction and Blumenthal technique of Manual Small Incision.

What is the endothelial count for taking decision of MSICS versus Phaco? Like, I told you, a normal endothelial count we all know is about 2000 plus. So, if your endothelium is anywhere 1000 or below, I would certainly urge towards as Manual Small Incision rather than Phaco. Between 1,000 to 2,000 you can decide depending upon the density of your cataract. The people how it is how and it matters your cornea as, et cetera. And how fluent you are in either of the techniques? Which out of the two procedures SICS or Phaco method of choice in post keratoplasty and why? In my hands, post keratoplasty I always choose a small incision because it’s most endothelium friendly in my hands. But it really depends on your comfort of the technique and how hard the cataract is, et cetera, how big your graph is.

Sir, when we combine Phaco or SICS and Pterygium, what precautions to be taken extra in such combined surgery? Nothing unusual, just make sure that if you’re using fibrin glue, it’s fresh. Don’t use glue which is a day or two old because then you maybe because it’s — you’re entering inside the eye so you don’t want to have a possibility of infection. We shouldn’t be using reusing glue anyway. But I do know that some people do that and it’s not a good idea, if you’re going to become binding to the cataract surgery. Finish your Pteryguim surgery first. Be careful that you don’t take too large a conjunctival autograft that you will not be able to approximate or conjunctival at the wound. If you think that that’s likely to happen then take your graft from inferior site rather than from the superior side, or from the side of surgery.

When you decide to put suture to this sclera, if you’re tunnel has gone too deep and you see choroid, what would you do? So, you don’t need to suture the sclera if the wound is holding. You have to check the wound at the end of surgery. If it is holding, you can leave it as it is. If you’re post graph scenario sometimes or it’s a young patient like who is likely to rub his eye then in such cases it’s over there just suture it up. If you’re a tunnel has gone too deep and you see choroid, then what you can do is you don’t have to panic. If it’s just a straight cut a very small cut, you can continue the surgery as usual, added more superficial plane. After everything is over, make sure you put a suture in the area where you gone deep and it really won’t cause a problem. If you’re a large area of Choroid has been exposed, then suture it up that area and then go 90 degrees across. If you’re superior, go temporarily, create a new wound and proceed with surgery as though nothing happened. It doesn’t really matter.

I notice you are mostly using three-piece lenses, is there a reason? Would can-opener isn’t it safer to use a single piece? You can use the single piece or a three-piece even with the can opener just to make sure that the optics are inside the bag. When you put a contact lens on and you can use a three-piece PMMA lens as well. When you put a contact lens in conjuctival autograft, won’t you worried that the contact leads get scrape with the graft? In fact, it’s the opposite. The graft will be secured by the contact lens edge. It won’t scrape it away. It helps to keep the graft in place. If you try the lens, you know.

What is the medical management of post opt. para central Descemet’s detachment and patient presenting after 15 days with Descemet fulls? If you’re if it’s a planar dismissed attachment, all you need to do is put a large bubble of anterior chamber and that can help. If the dismiss has scrolled on itself and sometimes it may not unfold on its own. In such a case if it’s a very small area of damage descemet you can wait and watch, sometimes the adjoining endothelium migrate slides over and that can overcome the edema after some time. If it’s a large area then you may want to just go in manually unfold that scroll. Or sometimes you need to do endothelial graft like a DMEK.

How to use Endo-illuminator? It’s very simple. It’s like a small metallic probe with the light at its tip. So, you can keep it on the cornea. Put viscoelastic on the cornea and directly keep it on the cornea at an oblique direction. You have to move it around. If you have a good assistant, it’s very useful that the assistant can put it at a certain angle in which you start seeing structures. If you’re not able to do that you can also take it in your non dominant hand and put it manually inside the eye like a second instrument right next to the structure that you want to see. It’s a very, very useful thing.

Can you please throw some light on soft shell technique? Like, I said earlier. First you put this dispersive viscoelastic to fill and then in that courts, all the structures in the anterior chamber including the endothelium and inside that you put a bowlers off cohesive viscoelastic like Healon or sodium hyaluronate.

What would be the criteria to manage Pterygium and cataract in the same setting? I think we have discussed this extensively. Any algorithm for IOL calculation, try to get a Keratometry. If you’re not getting from the same eye, you can take from the fellow eye.

What do, does it need learning curve can be done without observer? I do Phaco myself with no observation. Manual Small Incision Cataract says he does have a learning curve? It’s ideally done with guidance in the initial few cases at least. But if you have learned Phaco on your own, you should be able to learn this also. You can see some videos and don’t do the whole surgery at one go, you can start stepwise. Initially you can try by making a larger access than usual. And then if you’re trying to do a Phaco emulsification, try to first relapse and you place out of the bag into the sulcus, then you can push it back into the bag and continue with your Phaco. So, do you step by step and you can start by creating a scleral tunnel like you were doing a Blumenthal but only do a Phaco 2.8 or 2.2 incision and do your Phaco through that so you can practice your tunnel but not the entry. And once you’ve perfected with the tunnel then you can start making an anterior chamber entry and complete the rest of the steps. You could also just do the tunnel and go the opposite side and do a phaco emulsification through liberal root. So, you can do step by step and once you become comfortable, you can go ahead and do the whole surgery.

If the pupil is not dilating what will be approach? I like to use a Kuglen Hook to stretch the pupil unless it’s floppy. You could also just use a sphincterotomy once you have entered the anterior chamber, you can use the vannas or you can use micro vannas through the side port and that will help to enlarge your pupil. You can use pupil dilating rings but they will interfere with the nucleus coming out. So, rings are not a good idea for small incision.

Is it advised to do lens extraction with IOL implantation with PK in elderly patient about 40 without cataract? If you are doing a Penetrating Keratoplasty always it’s better to not do the cataracts surgery along with it because it can compromise outcome of your graft and also it can damage — you can end up with a wrong lens calculation. So, ideally you can do the cataract surgery later. Don’t be in hurry to remove the cataract in the primary setting. But if you think that there’s some practical considerations you can go ahead and do that because another thing that you will loses accommodation and that can sometimes not be very good for the patient.

Can be used by PMMA hard lens? Of course, you can. Do you do specular in all routine Phaco cases? No, I don’t. Only if I have some doubt about the endothelium I do it. You can see the endothelium in most of the cases on its reclaim by doing a speculum reflection. If you don’t know how to do that just look it up, it’s very easy to see the endothelium in high magnification on the slit lamp.

If the anterior chamber maintainer does causes endothelial touch, what can be done post-opt? You’ll just have to wait and see how it clears up. If the touch is very bad sometimes it can cause some permanent damage. But usually the anterior chamber maintainer is very small so that should usually recover. And sometimes unless it’s detached the descemet membrane.

MSICS in subluxated lens ozonolysis, yes it can be done, why not you can do, put a capsule attention ring just like you would in a Phaco emulsification. Just be careful about collapsing the nucleus. Make sure you have a large recesses, otherwise you will stress the zonules further. So, having a large access is important.

For cataract patients with Pterygium, do you have this conjunctival graft from the inferior conjunctiva to save the superior conjunctiva? If you ever anticipate possible, direct click to me. If you’re anticipating a possible, direct click to me. Please, don’t do a superior incision at all. You should do a temporal SICS if you’re doing a small incision, otherwise I do a Phaco emulsification because if you do a superior one then again that’s going to preclude your future trabeculectomy. And yes, so it’s ideal to take a conjunctival graft from inferior side or temporal side.

Do you manage microcornea with Colobama Brown cataracts? How do you manage? These are very, very challenging cases. And especially if you’re colobama is inferior, it can be a big challenge. So, again in these cases having small incision in your armamentarium really helps. And I often resort to that. And it may be a good idea to actually sit temporarily in these cases because the colaboma can then be used to your advantage. If it’s inferior sometimes it can cause some difficulty in maneuvers. Sitting temporarily may actually help you use that Colobama during your maneuvers to prolapsed the nucleus out of the pupil and deliver it out.

How would giving a suture significantly help in reducing SIA in SICS? So, suturing can be done if you are ending up with a lot of small incision. But then it’s kind of defeating the purpose of small incision isn’t it, you’re trying to do a suturless technique. In my hands I get about 1.5 to 1.75 diopter which is not too bad, you know. So, unless, say, you and if you have a lot of astigmatism pre-existing then you can try to put your site off your SICS on the steep access to kind of contract that and that can work well.

Please, do a webinar on refractive cataract surgery aiming Emmtropia especially planning incisions and IOL in different case scenarios. Yes, I can certainly do that, if all this wants once we do.

Sir, in combined Phaco or SICS with Pterygium, do you give topical steroids post endothelial debridement due to Pterygium removed? Yes, as usual, it’s not a problem.

Where could I found record of this lecture, please? I think you’ll find it on the Cybersight website by the end of today within 24 hours, they put it up.

Is necessary to do keratoplasty and endothelial Dystrophy after cataract surgery? It’s not always necessary. Sometimes, endothelium can hold on especially if you have a posterior polymorphous dystrophy, sometimes they never required on endothelial keratoplasty.

Absolutely brilliant presentation in MSICS, it is important to do a big enough CCC, what happens if it turns out small? What should we do? If a nucleus is not very big you can get away with a small CCC. But if you have a big nucleus you better have a big nucleus big CCC, otherwise you will have this own in the problem. You will have to end up enlarging their access which is not very difficult to do also.

Management for buttonhole, if it’s a small buttonhole you can change the plane complete the surgery and often you may not need to do anything else. If it’s a larger buttonhole, move to another site and make a new incision.

Do you always perform endothelial count? We’ve done that. Can you please repeat IOL calculation target power in DMEK, DSEK with hypertrophic shift? If it’s DMEK, you don’t need to do any change in the lens power. If you are, if it’s a DSEK, it will cause a hyperopic shift, so about minus 1 to 1.5 is what I would do for DSEK.

Good day, when do you remove sutures? After about two to four weeks you can remove switches anytime. Have we put, have we to put switchers? Not necessary, if your wound is holding, its not necessary.

How big is your recesses? My recesses in a small incision will typically be a t least 6.5 to up to 8 millimeters depending on the nucleus size.

ECC, is it no more used? Of course, not. ECCs your last resort, if SICS will, if you’re not comfortable with SICS please go ahead and do ECC, it’s perfectly okay. Post trabeculectomy, shall we see with hazy cornea? Such as, SICS would probably be difficult because you have a limbal conjunctiva to work with? You would probably want to a limbal wound either clear corneal Phaco or a limbal ECC and IOL.

How do you approach a patient with who needs trabeculectomy with a large Pterygium nasal temperol cataract? What order would you do and how do you preserve conjunctiva for trabeculectomy? So, you would do a temporal. I would then do a temporal phacoemulsification and Pterygium would be from the inferior Bulbar conjunctiva or from the IOL.

Do you do MSICs under topical anesthesia? Yes, you can. In fact, Blumenthal used to do it under topical. You can do it on a topical but it’s probably a good idea to infiltrate some anesthetic under the conjunctiva as well. So, topical plus of sub-conjunctiva and anesthesia is a good idea. But you don’t need to give a peribulbar bar or Retrobulbar block. How do you size your capsule recesses with a hyper mature black lens? I will size it at least 7 or 7.5, and if possible, 8 as largest possible. The good news is in these very brown black cataract, the Recesses doesn’t really run away to the periphery that much and it’s quite easy to do a large recesses in these very hard cataracts.

Big temporal incision with suture, is it medical legally without suture, is it medical legally safe? I don’t know the answer to that. But a lot of people all over the world are doing temporal SICS. And I think it’s an accepted technique now, as long as you’re conjunctiva is covering that area, it should be okay. But I personally don’t like to keep a temporal large wound. I feel more comfortable if it’s superior.

In triple patients, do you prefer Diamox, IV mannitol in all patient? If I’m doing a triple procedure, IV mannitol. Especially if it’s going to be a full thickness procedure like penetrating keratoplasty, IV mannitol is compulsory.

What do you use for calculating IOL power and what formula goes? There’s no one formula, of course, the newer generation formulas a better. But more than the formula, it is getting the right correct calculation of your Keratometry which matters in these cases and of course the excellent. And many of the new about biometers and the newer equipment like topography, the sensor topography can certainly help you.

Leading from incision site before closing eye, mostly towards the right side of incision, why and how to reduce? So, if you have gone through one of the perforating vessels, it can cause bleeding. Or at the angle if you have damaged the root of the iris, so if you’re having a lot of active bleeding put a large bubble of air let it stand for some time and that will tamponade your bleed and also stop the bleeding. If there is — and of course you can suture it up the area which is bleeding, the suture itself in help to tamponade the bleed.

If there is circumstantial congestion post, post opt following a Descemet’s detachment with Descemet’s post, does it indicate compromise cornea? And what is the treatment other than keratoplasty. So, you have to look at the cause for the edema, if it’s a Descemet’s detachment, you have to treat the Descemet’s detachment. Try to put a large bubble of air to tamponade it or unscroll it. If that’s not happening then sometimes just waiting will help to cure that edema. If that also doesn’t work then you’ll have to do in anything endothelial keratoplasty which is also not too bad results of fabulous nowadays.

How long the time after PK to do MSICS? I really one should wait till all the suture are out and the corneal shape has stabilized.

Dr. Swarup, and I have question here. I’m a last year off third resident from Indonesia. We’re trained to do ECC and phaco. Do you think for the later actual cases in life after residency, will SICS be extremely important to be mastered? Thank you. I’ve been several years into my practice now, and I still do use SICS. It’s a very, very good technique to have in your armamentarium. Especially if you’re having a problem during cataract surgery, nothing will help you like SICS. you must learn it.

For UbiD complicated cases Phaco has been described as the surgery of choice. Your comments, any special indications where MSICS is preferred, I don’t think it’s necessary. Any technique even SICS is perfectly okay. Rather than the technique, it’s the technique that causes minimum damage to the iris structure. So, whatever works in your hand whether it’s SICS or Phaco whichever can be done more safely, causing minimum damage to the pupil and the iris is what I would suggest. Phaco is perfectly okay too.

Some people discouraged for Limbal IOL because usually the recesses more, so after some time IOL comes out, your thoughts. If you don’t have an access, it may be a good idea to avoid affordable lens. But if you have an intact recesses and you put the lens well into the back, is not going to come out.

What are your thoughts on doing an envelope Capsulotomy Technique as opposed to can opener? Yes, that could also be done. But again any capsulotomy which is not a CCC, there is a risk of extension, so you have to be careful especially if you’ve got a large cataract.

How do you approach a patient who needs a trabeculectomy to me with a large Pterygium nasal temporal and cataract, what order would you do and how do you preserve conjunctiva for trabeculectomy, the commodification are available? So, same I think he wants to this questions, so I’m not going to repeat it.

Can affordable lens be used in the bag after this SICS if their recesses is large and would not enveloped the optic edge? Yes, it’s not a problem. You may have PCO but you can handle it later.

How do you handle premature entry? I think we’ve discussed that. You can go to one of the site and complete the surgery and switch it up this site.

Sir, can we have video recording of that surgery? Did you have any YouTube channel? I think they’re going to share these videos on the Cybersight. Otherwise if you want any other videos you can contact me directly. I’ll be happy to help.

Great lecture, thank you. Great videos, thank you. What is the frequency of CME after surgery? It’s just like any other cataract surgery. If you have not touched the Iris too much, you won’t have CME. If you’ve done a lot of manipulation damage the Iris, you can have CME. It will usually come at least two to four weeks after surgery. So, if you’re not getting optimal best character vision after surgery, look at the macula, can do OCTC.

Is there a risk off around leakage, how to prevent that? If your wound is not constructed, it will leak. If it’s constructed well, it will not leak. What precautions can we do for our calculation of combined Pterygium? I think we’ve done that. What is the ideal with of the internal lip wound? If it’s a big nucleus, 8 to 8.5 millimeter. Youngest age you do SICS, anybody who is not likely to rub the eye, you can do. Children, I would not recommend it because they would — it’s a big wound and if they rub the eye, the wound can open up.

How do you prefer the type of incision when K differences high, when you go temporal went 180 degrees is deep? Yes. Wherever it is deep, make your incision there. It will help to reduce the postoperative astigmatism.

Would you please put photo for your endo-illumination which light source do you use? I will try — I don’t have a picture of it. I’m sorry, you can just try and look for it on Google. I use a endo-illuminator which comes with my machine. My machine has a vitrectomy unit as well. So, all vitrectomy machines have a light source but you can use a standalone light source also. They are easily available at least in India.

Post opt medications in case of corneal thinning with corneal degeneration. As usually, if you’re epithelium is not damage, if you don’t have active infiltration. If it’s just an inactive thinning like in pellucid, just use your routine cataract medication. Excellent webinar in Q&A, thank you. How do you manage floppy Iris in MSICS? So, that’s a good question. It’s always a challenge in every situation. It’s a good idea to use high density viscoelastic and try to minimize fluctuations of the anterior chamber, so you want to avoid using an anterior chamber maintainer. Use a high density viscoelastic to push the iris down, gently manipulated the nucleus out of the pupil, you probably want to remove the entire nucleus into the anterior chamber in this scenario first. And you can use a sheet light to keep the Iris back and to help with the delivery of the nucleus in these cases.

But yes, I have used it in cases with floppy iris and you can get away with it. Just be careful about iris prolapsing because you have a large wound of large amount of iris comes out, you can end up with a Riddle Dialysis. In large DMD, what would you use SF6 or C3F8? You don’t need to use gas which lasts for too long, so even air is fine actually if we have a good amount of filled. But it’s SF6 or C3F both can be used whichever last lesser time used that one.

Does using anterior chamber maintainer throughout the surgery will not give SK in post opt? So, if the anterior chamber maintainer doesn’t slip out, it actually can be a very useful tool by per se, it will not cause endothelial damage especially if your flu is not directed against endothelium, direct the flow towards the iris. But if it slips out and detaches the descemet, then it can cause a problem.

Thanks a lot for taking time and answering questions. How can each — how can other eye biometry help? If you’re not getting a good keratometry in this side then you can take the other keratometry for the biometry. It’s not ideal but it can be a good surrogate.

Is Argentinian flag sign happy? Is it safe to continue as SICS? So, if you get an Argentinian flag sign just converted to a can opener and proceed as you would. But be a little careful, it’s not a problem. How to talk tackle Incision Bleeding has been covered, if combining Cataract with Pterygium even a trophic Pterygium with significant testing medicine, can plant Toric IOL? Yes, you can if the corneal shape has been stable for some time. So, I would suggest that observe the topography over a few months. And if its remaining stable, you can do, you can proceed with the Toric cleanse also.

Okay, I think we have come to the end of all the questions. Thank you everybody.

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April 10, 2020


  1. Can i depend on previous biometry taken some period ago before the patient decided to undergo the cataract surgery ( by which time the k readings can not be obtained due to the corneal disease ) ??

    1. Please submit this question as a Cybersight General Question and we will arrange for a cataract-refractive specialist to discuss the specifics of the case with you. Thank you!

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