Manual Small Incision Cataract Surgery Research Articles

Technique modifications in manual small-incision cataract surgery for left-handed cataract surgeons.

Learning manual small-incision cataract surgery (SICS) is essential for ophthalmic surgeons as it provides an alternative to phaco-emulsification in complicated cases. Nearly 10% of ophthalmic surgeons are left-handed. Left-handed surgeons do face more difficulties because of their laterality, which have been highlighted in various surveys even in other surgical specialities. Surgical training programs, residency programs, and fellowships have traditionally been designed considering the right hand as the dominant hand. Left-handed surgeons (LHSs) are at disadvantage as they are trained by right-handed surgeons (RHSs), which may result in more initial intra-operative errors. Intra-ocular lenses are also designed such that dialing into the bag is relatively difficult for LHSs. Developing customized training modules for LHSs can help them overcome the laterality challenges and enhance their surgical capabilities. In this article, we herein present a brief description of the SICS technique for LHSs, elaborating the crucial steps and customized maneuvers that, if performed differently, may make surgeries easier for them.

Commentary: Endoexpression technique of nucleus delivery in manual small-incision cataract surgery.

Commentary: Endoexpression technique of nucleus delivery in manual small-incision cataract surgery.

Manual small-incision cataract surgery and glaucoma - A dilemma of the duo.

Both cataract and glaucoma significantly affect the quality of life of an individual and they are often found to coexist, either primarily or secondary to one another. Clear-cut guidelines are not available for this subgroup of coexistent morbidities. Through this article, we attempt to discuss the risks and benefits of staged and combined surgery, their short- and long-term effects on the intraocular pressure and pre and postoperative management. The indication and type of surgery will depend on the type, severity and control of glaucoma, and the clinical significance of cataract; and the surgical outcome on the surgical technique used, site of surgery, use of anti-fibrotic agents, and most importantly, the surgeon's skill and experience.

Commentary: Modulation of the incision size for the correction of astigmatism in manual small-incision cataract surgery.

Commentary: Modulation of the incision size for the correction of astigmatism in manual small-incision cataract surgery.

Assessment of a high-fidelity, virtual reality-based, manual small-incision cataract surgery simulator: A face and content validity study.

To establish the face and content validity of the HelpMeSee Eye Surgery Simulator - a virtual reality-based cataract surgery simulator for manual small-incision cataract surgery (MSICS). The face and content validity were assessed on the sclero-corneal tunnel construction course. A questionnaire with 11 questions focused on the visual realism, with resemblance to real life surgery, and the training value of the simulator was developed. Thirty-five experienced MSICS surgeons participated in the study. Responses were recorded using a seven-point scoring system. Overall, 74.3% (26/35) of the respondents agreed that the overall visual representation of the eye and the instruments in the simulator were realistic. The task of injecting a visco-elastic through the paracentesis was reported to be the most visually realistic task with a mean score of 5.78 (SD: 1.09; range: 2-7). With regard to content validity, 77.1% (27/35) of the subjects felt agreed that the errors and complications represented throughout the entire tunnel construction module were similar to those encountered in real life; the task of entering the anterior chamber with the keratome had a mean score of 5.54 (SD: 0.98; range 1-7), being rated the highest in that aspect. Overall, 94.3% (33/35) of the subjects agreed that the simulator would be useful in developing hand-eye co-ordination. A similar number of 94.3% (33/35) agreed that based on their experience, they would recommend cataract surgical training on this simulator. The results suggest that the HelpMeSee Eye Surgery Simulator appears to have sufficient face and content validity for cataract surgical training.

One step beyond tomorrow; Ranjan manual small-incision cataract surgery (MSICS) marker - Welcome to the topical, flapless and astigmatism-free MSICS era.

The prevalence of blindness in India is 14.9 per 1000. Cataract causes 80% of this blindness. Most of these blinds are in the rural areas while the surgical service delivery channels are concentrated in the urban areas. This situation has many social impacts like loss of productivity, breakdown of interpersonal relationships, depressive manifestations, loss of self-esteem, and isolated humiliating life. Manual small-incision cataract surgery (MSICS; also SICS) is a low-cost, small-incision, high-valued cataract surgery that is principally employed in the developing world. In poor settings, MSICS also has several distinct advantages over phacoemulsification, including shorter operative time, less need for technology, and lower cost. Ranjan MSICS Marker is a tool which enables MSICS to be done under topical anesthesia easily with more precise and safe incision making along with more control on surgery induced astigmatism.

Novel tunnel staining technique to reduce premature entry in manual small-incision cataract surgery.

Mastering manual small-incision cataract surgery (MSICS) for beginner surgeons is difficult. In the initial days of residency or training, surgeons struggle to make a proper scleral tunnel and keratome entry. It commonly results in premature entry and iris prolapse. Most of the literature has shed light on premature entry during tunnel construction by a crescent blade, whereas a significant majority of iris prolapse happens due to improper keratome entry. This novel trypan blue dye-assisted tunnel staining (TBTS) technique helps in proper tunnel demarcation which can reduce the incidence of premature entry with a keratome.

The prediction capability of a cataract surgery risk stratification model based on a large electronic medical record dataset.

The aim of this study was to develop a risk stratification system that predicts visual outcomes (uncorrected corrected visual acuity at one week and five weeks postoperative) in patients undergoing cataract surgery. This was a retrospective analysis in a multitier ophthalmology network. Data from all patients who underwent phacoemulsification or manual small-incision cataract surgery between January 2018 and December 2019 were retrieved from an electronic medical record system. There were 122,911 records; 114,172 (92.9%) had complete data included. Logistic regression analyzed unsatisfactory postoperative outcomes using a main effects model only. The final model was cross-checked using forward stepwise selection. The Hosmer-Lemeshow goodness of fit test, the Bayesian information criterion, and Nagelkerke's R2 assessed model fit. Dispersion was calculated from deviance and degrees of freedom and C-stat from receiving operating characteristics analysis. The final phacoemulsification model (n = 48,169) had a dispersion of 1.08 with a Hosmer-Lemeshow goodness of fit of 0.20, a Nagelkerke R2 of 0.19, and a C-stat of 0.72. The final manual small-incision cataract surgery model (n = 66,003) had a dispersion of 1.05 with a Hosmer-Lemeshow goodness of fit of 0.00015, a Nagelkerke R2 of 0.14, and a C-stat of 0.68. The phacoemulsification model had reasonable model fit; the manual small-incision cataract surgery model had poor fit and was likely missing variables. The predictive capability of these models based on a large, real-world cataract surgical dataset was suboptimal to determine which patients could benefit most from sight-restoring surgery. Appropriate patient selection for cataract surgery in developing settings should still rely on clinician thought processes, intuition, and experience, with more complex cases allocated to more experienced surgeons.

Stabilization of refraction and timing of spectacle prescription following manual small-incision cataract surgery.

To determine the stabilization of refraction at 2 weeks following MSICS by comparing the difference in spherical, cylindrical component and also spherical equivalent of refraction of 2 weeks follow-up with that of 6 weeks following surgery. The difference of spherical, cylindrical component and also spherical equivalent of refraction at 2 weeks and 6 weeks follow-up of 194 eyes that underwent uncomplicated MSICS with implantation of PMMA IOL conducted by a single experienced surgeon were compared to find out the amount of change and its significance was statistically tested by Wilcoxon-Signed Rank Test. The difference in spherical power (0.04 ± 0.30), cylinder power (0.03 ± 0.40), and spherical equivalent (0.06 ± 0.34) were very small and not significant statistically (P-value ≤0.05). Necessary spectacle correction can safely be prescribed after 2 weeks following MSICS as subjective refraction stabilizes by that time without undergoing significant change. However, our observation was applicable in patients who had an uneventful cataract surgery without any risk factor, which can delay wound healing or cause poor visual outcome.

Preferred practice of cataract surgery in brown cataract: A questionnaire-based survey among Indian ophthalmic surgeons.

To determine the most preferred method of operating brown cataracts among ophthalmologists in India. A cross-sectional, questionnaire-based study was conducted among ophthalmologists all over India through electronic and social media from May 1 to June 15, 2022. All single, voluntary entries within the stipulated time period were accepted for analysis. A total of 230 ophthalmologists participated in the study among which 198 (86%) preferred Manual small-incision cataract surgery (mSICS) as the first option. This was preferred due to the high risk of complications associated (40, 33.6%) as well as endothelial damage due to increased Phaco power (53, 47.9%). The majority of the surgeons (162, 70.4%) preferred a superior tunnel for SICS, and 51.7% (119) performed continuous curvilinear capsulorhexis in 100% of their cases. The most common complication encountered was posterior capsular rupture (PCR) (66%), followed by zonular dialysis (ZD) (18.7%), whole bag removal (8.3%), and Descemet's membrane detachment (7%). Despite diverse recent new modalities of Femto Laser assisted cataract surgery (FLACS). Phakonit, and Smart Intraocular Lens (IOLs), the majority of ophthalmologists still find the manual small-incision cataract surgery (mSICS) procedure a safe surgery for mature brown cataracts.

Vacuum-assisted cortex removal - A novel change to the tradition.

In developing countries, manual small-incision cataract surgery (MSICS) has surfaced as the cost-effective alternative to phacoemulsification. The Simcoe irrigation-aspiration cannula was developed nearly 40 years ago and is still the most frequently employed tool for cortex aspiration. Although it stands unsurpassed, here we attempt to introduce an addition to the existing Simcoe cannula to achieve a dynamic and controlled vacuum with the added advantage of less physical strain and an effective volume of aspiration. The vacuum-assisted cortex removal device is based on a simple spring action mechanism, where the relaxation of the spring pushes the plunger up and thereby generates a controlled vacuum.

Comparison of different endophthalmitis prophylactic measures in cataract surgery - An analysis of 2.4 lakh cases.

To compare different endophthalmitis prophylaxis methods adopted in cataract surgery (manual small-incision cataract surgery and phacoemulsification) between the years 2013 and 2021 in the community eye care section of a tertiary eye care hospital in South India and report their outcomes. All cataract surgeries performed from January 2013 to December 2021 (2,46,874 surgeries) at a single center were included in this retrospective study. The different endophthalmitis rates with each regimen were analyzed and evaluated. 70,081 surgeries were performed from January 2013 to February 2015, where Tobramycin was added to Balanced Salt Solution (BSS) (Group A). From March 2015 to January 2017, 63,245 surgeries were performed when intracameral Moxifloxacin was given (Group B). From February 2017 to December 2021, 1,13,548 surgeries were performed were Amikacin was added to BSS (Group C). In total, 42 cases of postoperative endophthalmitis were reported during the study period (0.02%). There was no significant difference in the endophthalmitis rates between groups A and B (P = 0.4152); however, there was a significant decrease in endophthalmitis rates in group C when compared with group A (P = 0.04) and group B (P = 0.006). There was a significant reduction in the rates of endophthalmitis following the addition of amikacin in irrigating BSS. Nocardia was one of the predominant organisms isolated from these endophthalmitis patients. This is the first single-center study to report a comparative analysis of different endophthalmitis prophylactic measures in a community eye care set up with a high incidence of Nocardia endophthalmitis prevented with amikacin in BSS irrigating solution.

Long-term outcomes of small-incision cataract surgery in patients with uveitis.

To evaluate the long-term outcomes of manual small-incision cataract surgery (MSICS) in eyes with uveitis. Patients who underwent MSICS for uveitic cataract from 2009 to 2019 were retrospectively evaluated. Visually significant cataract and presence of less than five cells per high-power field in the anterior chamber for a minimum of 3 months were the prerequisites for surgery. Patients with follow-up less than 9 months were excluded. After exclusion, 283 eyes of 264 patients were evaluated. The mean age of patients was 44.3 ± 11.3 years. The mean follow-up duration was 22 ± 11.5 months. The mean surgical time was 11.2 ± 3.2 min. One hundred and seventy-two eyes (60.8%) had anterior uveitis, 78 (27.5%) had posterior uveitis, and 33 (11.7%) had panuveitis. At the final follow-up, 253 eyes (88.4%) had corrected distance visual acuity (CDVA) better than 0.6 log of minimum angle of resolution (LogMAR) unit. The final endothelial cell counts were significantly (analysis of variance [ANOVA], P = 0.001) lower in eyes with human leukocyte antigen (HLA)-B27-associated uveitis and in eyes with idiopathic anterior uveitis. Patients on systemic corticosteroids had significantly better (P = 0.031) final visual acuity than those without preoperative corticosteroids. Recurrent uveitis (43.8%), Posterior capsule opacification (PCO) (19.4%), glaucoma (8.5%), cystoid macular edema (CME; 13.5%), and Epiretinal membrane (ERM) (5.6%) were the frequent complications. A significantly worse (ANOVA, P = 0.001) visual prognosis was seen in patients with Vogt-Koyanagi-Harada disease (VKH), sarcoidosis, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), and serpiginous choroiditis. MSICS is safe in most cataracts due to uveitis and results in improvement in CDVA at 9 months. Posterior capsule opacification, macular edema, persistent uveitis, etiology of uveitis, and use of preoperative steroids significantly influenced the visual outcome.

Snare assisted manual small-incision cataract surgery: Single solution for any grade of cataract.

Cataract surgery is constantly evolving with new techniques, machines, and procedures entering the lexicon. With the modernization, the cost of surgery is increasing with respect to the surgeon, patient, and the society. Early rehabilitation with modern minimal access techniques reduces the societal cost of intervention. Manual small-incision surgery is simple, safer, and cheaper when contrasted with the cost and steep learning curve of machine-driven surgeries. A nucleus of a normal size is 6 mm, which can be bisected; 3 mm longitudinal fragments can be removed through 3.5 to 4.5 mm incision, and a large nucleus of 9.0 mm can trisected and removed through 3.5 to 4.5 mm. The limbal tunnel incision is 3.5 mm, which is close to 2.8 mm phacoincision, so it gives all the advantages of modern phacosurgery. The search of an ideal technique for manual phaco-fragmentation leads us to this specially designed snare (designed by the first author AS) which can tackle any grade nucleus. The nucleus can be bisected or trisected with ease. The technique has been around for 2 decades. There is a small learning curve. The complications are few and can be minimized with practice and simulation. It is a safe, valid, repeatable, and generalizable surgical procedure.

Why learn manual small-incision cataract surgery?

Why learn manual small-incision cataract surgery?

Architectural analysis of subconjunctival oblique limbus incision techniques in manual cataract extraction surgery by optical coherence tomography imaging.

The purpose was to assess the profile of subconjunctival oblique limbus incision (SCOLI) design by using anterior-segment optical coherence tomography (AS-OCT) and try to emphasize the proper technique of wound construction. The structural dimensions and integrity of the wound were acquired from the patients, who had undergone manual small-incision cataract surgery with SCOLI techniques, using a Canon OCT anterior-segment imaging system on the first postoperative day. The use of AS-OCT allowed for an in vivo evaluation of SCOLI in high definition. The radial OCT scan image showed three staggered incisions, including conjunctiva incision, scleral entrance, and inner corneal lip. A tangential scan demonstrated that the internal lip is parallel to the curvature of the peripheral cornea. The en face image showed an asymmetric 4 arc-shaped configuration rather than a symmetrical one. In conclusion, AS-OCT could be used to analyze SCOLI to determine optimal wound construction and geometry. The results of this study indicated that an asymmetric 4 arc-shaped limbus tunnel incision was superior to the conventional linear equivalent in stability and nucleus delivery.

Commentary: Changing era of modern cataract surgery - The role of virtual reality-based simulators in manual small-incision cataract surgery training modules.

Commentary: Changing era of modern cataract surgery - The role of virtual reality-based simulators in manual small-incision cataract surgery training modules.

Commentary: Surgically induced astigmatism in manual small-incision cataract surgery incision types: Is the correlation linear?

Commentary: Surgically induced astigmatism in manual small-incision cataract surgery incision types: Is the correlation linear?

Study of changes in pre-existing against-the-rule astigmatism after temporal manual small-incision cataract surgery using frown, straight, and smile incisions.

To assess the change in the amount of astigmatism caused by frown, straight, and smile incision in patients with pre-existing against-the-rule (ATR) astigmatism of more than and equal to 1 diopter. This is a prospective, comparative study conducted over 18 months on 60 patients. Twenty patients were allocated to each incision using simple random sampling. Demographic details, best-corrected visual acuity (BCVA), intraocular pressure (IOP), anterior and posterior segment evaluation, and A-scan were done. An average of three measurements of K horizontal (Khavg), K vertical (Kvavg), and difference between the two (Khavg - Kvavg) were taken using manual keratometry. All surgeries were performed by a single surgeon. All the data analyses were performed by using IBM Statistical Package for the Social Sciences (SPSS) version 20 software. Frequency distribution and cross tabulation were performed to prepare the tables. In frown incision, Khavg - Kvavg was significantly decreased on day 45 from the preoperative value (P < 0.001), followed by straight incision (P < 0.001), and smile incision (P < 0.001). Maximum decrease was observed in frown incision (49.15%) followed by straight (37.75%) and smile (28.57%) incisions. Our results are consistent with reduction of pre-existing ATR astigmatism with temporal incisions, and frown incision seems to be the best approach.

Two-mm chord manual small-incision cataract surgery with phacofracture: A brief exposition of the surgical technique.

We describe a surgical technique for manual small-incision cataract extraction with 2-mm chord incision with phacofracture. The authors describe a curvilinear 2-mm chord incision 1.5 mm behind the limbus and antiparallel to the limbus with back cuts of variable length; 1.5 mm for foldable lenses and 2.5-3 mm for the rigid nonfoldable lenses. Continuous curvilinear capsulorhexis with a 26-G bent needle cystitome (or Utrata forceps) is followed by cortical cleaving hydrodissection and cartwheeling of the nucleus into the anterior chamber. A specially designed Sahu modified vectis (SMV) and a flattened visco cannula are used for the phacofracture. The heminuclei are removed along their longitudinal axis and direct implantation of the pseudophakos. Surgically induced astigmatism was found to be a mean change in astigmatism of 0.14 DCyl when the axis was ignored. Corneal endothelial counts were not vastly different from the routine manual small-incision and phacoemulsification at 3 months of follow-up. The technique used here by the surgeon for cataracts of any C (1-5) or any P (1-5) to grade NC4 NO4 as graded by the LOCS III. Case selection is of paramount importance. Two-millimeter chord MSICS with phacofracture can deliver low astigmatism and good visual recovery in cataract surgery.