Manual Small Incision Cataract Surgery (MSICS) Ashok Garg, Luther L Fry, Francisco J Gutiérrez-Carmona, Amulya Sahu
INDEX
A
3 mm manual SICS 43
ACM in phacoemulsification 208
mini-incisional surgery 209
Anterior capsulotomy 11
B
Blumenthal's technique in MSICS 153
advantages 173
anterior chamber main-tainer (ACM) 154
capsulotomy 158
closing up 172
cortical clean up 168
hydroprocedures and
nucleus prolapse 163
IOL insertion 170
principle 154
scleral incision 159
side ports and ACM port 155
tunnel and internal opening 159
C
Capsulorhexis 45
Caveats 28
Closed chamber manual phacofragmentation 137
Cortex aspiration 21
D
Delivering the nucleus out of the bag 49
Delivery of nucleus into the anterior chambers 230
Delivery of the nucleus out of the AC 50
H
Hydrodissection 13, 48
Implantation of intraocular lens 102
advantages 108
disadvantages 110
I
Intraoperative complications and their avoidance in small incision cataract
surgery 278
capsulotomy 280
dialysis or rupture of the
posterior capsule 281
iris trauma 283
nuclear luxation 280
wound construction 278
M
Manual multiphacofragmen-tation (MPF) 31
surgical technique 34
anterior capsulotomy 34
extraction of the cortex and remains
of nucleus 39
hydrodissection and luxation of the
nucleus 36
incision 35
IOL implantation and wound closure 40
manipulation of nuclear fragments 39
nuclear fragmentation 37
Manual phacocracking 55
complications 60
visual outcomes 60
principles 56
surgical techniques 56
Manual small incision cataract surgery using
irrigating vectis 177
surgical procedure 178
capsulotomy 179
irrigation-aspiration of the cortext 185
management of hard cataracts 184
nucleus removal 180
peritomy 178
scleral tunnel and side port incision 178
Modified Blumenthal technique 202
assisted delivery 205
insertion of ACM 202
principle of the technique 204
MSICS in difficult situations 213
cataracts with existing filtration blebs 225
cataracts with pseudoexfo-liation 224
hard black cataract 222
small pupil 214
managing intraopera-tive miosis 215
managing non-dilating pupil 216
technique of stretching small pupil 217
subluxated cataracts 223
white cataract 219
N
Nucleus delivery 14
Nucleus management by viscoexpression technique
in manual SICS 121
P
Phacofracture and phaco-section 207
Phacofracture techniques in SICS 113
surgical technique 114
anesthesia 114
capsulorhexis 115
complications 119
hydroprocedure 116
incision 115
nuclear luxation 116
nucleus delivery 117
Phacosection technique in MSICS 61
cortical aspiration 100
entry into the eye 70
add on anesthesia 71
peritomy 73
preparation 70
separation of eyelids 71
superior rectus 72
fluidics and open and closed chamber concepts 80
anterior capsulotomy 82
instrumentation 65
6 mm marker 69
cannulas 67
cystitomes 66
irrigating fluid 69
methylcellulose (HPMC) 69
scleral tunnel blades 65
sinskey hook 68
wire vectis 69
nucleus management 88
hydroprocedures 88
patient selection, preparation and
anesthesia 62
anesthesia and akinesia 63
patient preparation 63
tunnel incision 74
Postoperative complications and their avoidance in MSICS 284
corneal edema 284
high intraocular pressure 284
postoperative endophthalmitis 285
shallow anterior chamber 284
R
Removal of nucleus out of the wound 232
various techniques 232
Blumenthal technique 233
chop bisector/chop trisector and chopsticks technique 253
double wire snare splitter technique 266
fish hook technique 257
hybrid technique 261
jaws slider pincer technique 263
manual multiple phacofragmentation 248
manual phacocracking 270
manual phacofractrue Cardona's technique 244
nucleus removal using irrigating wire vectis 234
phaco sandwich technique 246
phacofracture 238
phaco-punch technique 260
prechop manual phacofragmentation 251
quarters extraction technique for manual phacofrag-mentation 253
use of claw vectis 254
using of plain wire vectis 255
viscoexpression 237
S
Small pupils 7
Sutureless cataract surgery with nucleus extraction: fishhook technique 187
hook 188
learning curve 199
outcome 197
special highlights 199
technique 190
capsular opening 191
completing the surgery 197
hydrodissection and nucleus mobilization 192
nucleus hook extraction 193
T
Tenon's capsule 123
U
Update on various nucleus delivery techniques in manual small incision cataract surgery 229
V
Versatility of anterior chamber maintainer (ACM) in SICS 201
Viscoexpression of epinucleus 132
Viscoexpression of the nucleus 131
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Chapter Notes

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Small Incision Planned ExtraCHAPTER 1

Luther L Fry
(USA)
2
 
INTRODUCTION
In this chapter, I would like to describe a small incision manual technique which I have used since 1985. It involves “sandwiching” the nucleus out between a lens loop and spatula. This technique uses an incision of 7.0 mm. It can be used with capsulorhexis or with any other type of capsulotomy, such as can-opener. This 7.0 mm “frown” incision is self-sealing in the majority of cases, and does not require a suture. This larger incision does give more astigmatic shift than a 3.0 mm phaco incision, however this can be of benefit if one operates on the steep axis of K.
This technique works as well with rock-hard nuclei as with soft nuclei. It can be done with inexpensive reusable instruments, and may be more appropriate than phaco in situations where finances are limited.
Topical anesthesia with intracameral lidocaine is used. I presently prefer 2 percent lidocaine gel. The 1 percent nonpreserved intracameral lidocaine seems to sting less if it is made-up by diluting 2 percent nonpreserved lidocaine 50/50 with BSS.
 
INCISION
A side-port is made with a 15° blade. A few tenths cc of 1 percent nonpreserved lidocaine are instilled (Figures 1.1 and 1.2). The eye is filled with viscoelastic through the side-port (Healon GV® is presently my preferred viscoelastic).3
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FIGURE 1.1: Side port
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FIGURE 1.2: Lidocaine instillation
An 8.0 mm peritomy is made with scissors and bleeding is cleared up with wet-field cautery (under topical anesthesia, this may cause a slight sting. This, and the 4cauterization closure of conjunctiva at the end are normally the only times the patient feels anything. The discomfort is minor, and not a problem if the patient is forewarned). A superior rectus suture is not used. The incision site is on steep axis of “K” for cylinder 1.0 diopter or greater. For less than 1.0 diopter cylinder, temporal approach is preferred. Deep set eyes are also approached temporally. A limbal relaxing incision opposite the incision is added for cylinder greater than 2 diopters (Figures 1.3 to 1.5).
A “frown” incision is made with a guarded diamond knife set at 0.25 mm. The incision is dissected forward into clear cornea with a bevel-up crescent blade (Figures 1.6 and 1.7). Superior incisions are dissected about 1.0 mm into clear cornea and temporal about 1½ mm into clear cornea (the initial groove can also be free-handed with either the crescent blade or other blade, I feel the guarded diamond gives a better and more reproducible groove).
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FIGURE 1.3: Peritomy
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FIGURE 1.4: Cautery
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FIGURE 1.5: Limbal relaxing incision
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FIGURE 1.6: “Frown” incision
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FIGURE 1.7: Dissect into clear cornea
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The anterior chamber is entered with a 3.2 mm keratome at the depth of this scleral flap, giving a self-sealing internal flap. Additional viscoelastic is placed (Figures 1.8 and 1.9).
 
SMALL PUPILS
Small pupils are managed by stretching them out with two Kuglen hooks. One stretch, limbus-to-limbus, is all that is necessary. Additional stretches give little additional effect. Stretching slowly may help to avoid rupturing the sphincter.
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FIGURE 1.8: Keratome entry
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FIGURE 1.9: Additional viscoelastic
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FIGURE 1.10: Small pupil
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FIGURE 1.11: Stretch beginning
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FIGURE 1.12: Fully stretched
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FIGURE 1.13: Side port
Hold for a second or two at maximal stretch. Then expand the iris out with viscoelastic (Figures 1.10 to 1.13).
After pupil stretching, the pupil may be permanently larger than before, with crenated edges, particularly if it was very small and nondilatable preoperation. In these cases, it might be advisable to use a 6.0 mm or larger optic (I prefer 7.0 mm optics in all cases). This larger pupil is actually a benefit in allowing easier fundus viewing. I think you will be impressed by the ease and safety of this pupil stretching maneuver, and by the relatively normal appearance of the pupil postoperation.11
 
ANTERIOR CAPSULOTOMY
Any type of capsulotomy works well with this procedure. I prefer a capsulorhexis. The capsulorhexis, however, needs to be made as large as possible to allow nucleus tip-up. A can-opener capsulotomy works well also and is used if there is difficulty with the capsulorhexis. For mature cataracts, capsular staining under an air-bubble with either ICG or Trypan Blue (Vision Blue®, from Dutch Ophthalmic) makes the capsulorhexis much easier (Figures 1.14A to D).
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FIGURES 1.14A to D: Use of trypan blue (Vision Blue®)
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FIGURE 1.15: Start of capsulorhexis
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FIGURE 1.16: Completion of capsulorhexis
I prefer a Gimbel Utrata forceps for the capsulorhexis. This forceps has sharp tips so the capsule can be penetrated and the rhexis completed without changing 13instruments. I start in the middle and spiral out. Re-deepen with viscoelastic anytime the tear wants to “head south” (Figures 1.15 and 1.16).
 
HYDRODISSECTION
Complete hydrodissection is done, with the cannula just beneath the anterior capsule, to loosen the nucleus and get it rotating freely. Generally one fluid wave to the right and one to the left will be adequate. I like to use a spatula through the side-port and the hydrodissection cannula through the incision to bimanually rotate the nucleus after hydrodissection (Figure 1.17).
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FIGURE 1.17: Bimanual nucleus rotation
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NUCLEUS DELIVERY
After capsulotomy, the 3.2 mm incision is enlarged to 7.0 mm. I find that a 5.2 mm keratome works best for this. The crescent blade also works fairly well. Attempt to maintain the internal self-sealing incision all the way across (Figure 1.18).
The chamber is refilled with viscoelastic. A Kuglen hook in the left hand nudges the nucleus gently away from the incision. The spatula catches the superior pole of the nucleus at the equator and tips it up. Using the two instruments, the nucleus is then cartwheeled through the capsulorhexis and pupil (Figures 1.19 to 1.22) into the anterior chamber (as an alternative, it may be “somersaulted” end-over-end into the anterior chamber).
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FIGURE 1.18: Enlarge to 7.0 mm
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FIGURE 1.19: Nudge nucleus away from incision with spatula, retract capsulorhexis edge slightly with Kuglin hook
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FIGURE 1.20: Catch edge of nucleus with Kuglin hook
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FIGURE 1.21: Rotate nucleus through rhexis
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FIGURE 1.22: Continue to rotate until nucleus is anterior to capsule and iris
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If nucleus tip-up is difficult, aspirate the cortex off the top of the nucleus with the 0.3 IA tip, refill with viscoelastic, and attempt tip-up again.
Additional viscoelastic is placed beneath the nucleus. The lens loop is placed beneath the nucleus and the spatula on top. The nucleus is extracted, “sandwiched” between the two instruments. The outer portion of the nucleus will be sheared off with this technique, but it is soft and easily aspirated or irrigates out of the self-sealing incision with gentle pressure on the posterior wound lip (Figures 1.23 to 1.26).
If the nucleus breaks in two during removal, rotate the residual fragment so it is oriented with its long axis perpendicular to the incision. Add additional viscoelastic to blow the iris back and resandwich it (Figures 1.27 to 1.29).
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FIGURE 1.23: Sandwich the nucleus between the lens loop and spatula
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FIGURE 1.24: Extract the nucleus with the two instruments
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FIGURE 1.25: Nucleus out, between the two instruments
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FIGURE 1.26: Two instruments holding nucleus, side view
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FIGURE 1.27: Piece of nucleus breaks off
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FIGURE 1.28: Rotate residual nucleus
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FIGURE 1.29: Add viscoelastic and resandwich
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Large brunescent nuclei may be extracted through a 7.0 mm incision by purposely breaking off a superior wedge, then rotating 90° and removing. This is done by placing the lens loop and spatula one-third of the way down the nucleus and pinching off a fragment, reducing its diameter. Then, rotate long axis perpendicular to the incision and sandwich (Figures 1.30 to 1.33).
 
CORTEX ASPIRATION
Cortex is aspirated with the technique of your choice. I prefer automated technique with 0.3 IA tip. Manual technique also works well. If there are damaged zonules or a break in the capsule, I go to a “dry” technique, with manual cortex aspiration with a 27 gauge cannula on a 3 cc syringe under viscoelastic. A noncohesive viscoelastic, such as Viscoat, works better in this situation than Healon. A Morcher capsular support ring is helpful in cases with damaged or absent zonules.
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FIGURE 1.30: Instruments one-third of the way down the nucleus
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FIGURE 1.31: Break-off a wedge
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FIGURE 1.32: Rotate the nucleus
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FIGURE 1.33: Add viscoelastic and resandwich
A safety suture is not necessary. If there is a tendency to iris prolapse, this usually means a self-sealing incision has not been obtained and an “X” suture will be required at the end of the case. Residual epinucleus can be washed out of the wound by slightly depressing the posterior lip while irrigating with the IA tip. This is somewhat more efficient than aspirating epinucleus. Stubborn cortex can be assisted into the 0.3 IA tip with the “potato masher” maneuver (Figure 1.34).24
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FIGURE 1.34: “Potato masher” maneuver
Subincisional cortex can be more easily removed by splitting irrigation and aspiration and inserting the aspiration cannula through the side-port (Figure 1.35). These instruments and adaptor are available fairly inexpensively from ASICO (Table 1.1).
Viscoelastic is used to expand the capsular bag. A 7.0mm lens fits snugly through the incision. If squeezing is required, hold the eye with the closed 0.12 forceps inserted into the side-port (holding the flap risks tearing it). Insert the leading loop of the lens first, then the optic to avoid loop crimping (Figures 1.36 to 1.38).
Aspirate viscoelastic. The internal flap is sealed by pressurizing the eye with BSS through the side-port. Blood in the wound gives a Seidel effect to demonstrate any leak.25
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FIGURE 1.35: Irrigation through the incision and aspiration through the side-port for subincisional cortex
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FIGURE 1.36: Loop in first
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Table 1.1   Instruments list
LENS LOOP
Morrison Lens Loop-ASICO #AE2545 ($97.00)
SPATULA
Fry Spatula ½ mm-ASICO #AE2052 ($78.00)
KUGLEN HOOK
Kuglen Iris Hook and Lens Manipulator Straight-ASICO #AE2230 ($113.00)
BIMANUAL I-A SET
SIDE-PORT ADAPTOR
Fry Infusion Handle-ASICO #AE7389 ($24.00
ASPIRATING CANNULA
Anis Cortex Aspirating Cannula-ASICO #AE7403 ($45.00)
IRRIGATING CANNULA
Fry Cannula-ASICO #AE7190 ($17.50)
DISPOSABLE INSTRUMENTS (can be reused until dull)
(Available from many manufacturers-these are the ones I use)
Crescent Knife
Alcon #8006594002 (bevel up)
$133.00 (6)
$22.17 ea
Slit Knife-3.2 mm
Alcon #8065992961
$127.00 (6)
$21.17 ea
15° blade-#75 beaver blade
5.2 mm Keratome
Medical Sterile Products-Keratome Blade 5.2 mm, rounded tip
#55B-5.20 RT
$14.00
The chamber depth can also be observed to demonstrate no leak. If the chamber deepens with pressurization and does not shallow once the pressurization cannula is removed, self-sealing is indicated. This should occur in 95 percent of cases (Figure 1.39).27
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FIGURE 1.37: Hold through side-port
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FIGURE 1.38: Lens into bag
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FIGURE 1.39: Fill through side-port
Conjunctiva is brushed over the wound and sealed with wet-field cautery (Figure 1.40).
 
CAVEATS
This technique is viscoelastic-dependent. Be sure to have plenty of viscoelastic both in front of the nucleus and behind it when sandwiching. Attempting to remove the nucleus under air will result in striate keratopathy. This procedure does, however, work well with methylcellulose, or with any other viscoelastic.
When starting out, use a larger incision, possibly 8.0 mm; then gradually decrease the incision size as experience is gained. Where cost is a factor, if an X-suture is needed with these larger incisions, the 10-0 nylon suture can be placed in a 4 × 4 and can be autoclaved and reused (Vicryl® or Dexon® will not withstand autoclaving).29
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FIGURE 1.40: Seal conjunctiva with wet field cautery
It is possible to engage iris inferiorly between the spatula and nucleus, particularly in a very mature cataract where you cannot see the lens loop through the nucleus. This can result in an iridodialysis. This has occurred to me 3 times out of approximately 10,000 cases. Just be aware this can happen, and it will not happen to you.
As with any surgical procedure, this procedure is more easily learned by watching video tape than with a written description. This procedure was shown on Bobby Osher's Video Journal of Cataract and Refractive Surgery Vol IV, Issue 1, 1988, and on the Video Journal of Ophthalmology, Vol IV, Number 4, 1988. It is also in the ASCRS Film Festival Library 1987 and 1991, and in the ESCRS Video Library, 1999. If none of these are available to you, please feel free to contact me at my office in Garden City, Kansas, for a Video of the procedure.