Master’s Guide to Manual Small Incision Cataract Surgery (MSICS) Ashok Garg, Francisco J Gutiérrez-Carmona, Keiki R Mehta, MS Ravindra
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1Introduction and Relevance of MSICS
2

Clinical Significance and Relevance of Manual Small Incision Cataract Surgery in 21st Century EraCHAPTER 1

Ashok Garg
(India)
 
INTRODUCTION
Medical Science has seen tremendous advancements in last three decades worldwide. Ophthalmology specially cataract surgery has undergone significant changes from ICCE-ECCE with IOL-Phacoemulsification– Microphaco and coaxial Phaco. Phaco and Microphaco surgery is being performed by Eye surgeons all over the world specially in developed countries. This is most elegant surgery but with a high cost which cannot be 100% practicable in developing countries where cataract surgery volume is very high. Manual small incision cataract surgery (MSICS) has emerged as first choice alternative to phacoemulsification which retains most of the advantages of phaco can be delivered at a lower cost even in high volume cataract surgery programmes. MSICS achieves a best unaided visual acuity with rapid Post-surgical recovery and minimal surgery related complications. MSICS is a precise surgery for primary to the most advance level of patient care in modern cataract era. MSICS techniques have been neglected in the world literature except for few quality international books and journals. Clinical significance of MSICS has increased manifold related so safety provided by small incision and neutrality in astigmatism, a vital factor in realization of best postoperative visual acuity and ability to implant modern intraocular lenses and faster rehabilitation.
MSICS is the effective and best way of removing large back log of cataract surgery in developing countries at a affordable cost with similar visual results as in phacoemulsification. Moreover, in high grade density cataracts MSICS is certainly better than phaco in terms of visual results and corneal endothelium protection. A number of leading international cataract surgeons have shown in their parallel clinical trials (MSICS Vs Phaco) that MSICS is certainly better in all types and grades of cataracts with lost cost and maintenance demand of the equipments. In my opinion as a frequent worldwide guest faculty speaker as Brand Ambassador of World Health Organization that any eye surgeon doing MSICS can be assured that they are performing state-of-the-art cataract surgery for their patients with visual results as good as phacoemulsification.
As compare to phacoemulsification MSICS has less steep and less expensive learning curve. MSICS is much easier to learn and master even for the novice. However, one step is important to begin with conversion from ECCE to MSICS should focus on the making of a tunnel which differentiates MSICS from ECCE. One should have enough experience of tunnel making on goat's eye before converting to MSICS.
 
OBJECTIVES
The main objective in modern cataract surgery is to achieve a better-unaided visual acuity with rapid post-surgical recovery and minimal surgery related complications. Early visual rehabilitation and better-unaided vision can be achieved only by reducing the incision size. The size of the incision in turn depends on mode of nucleus delivery and type of intraocular lens (rigid or foldable). In standard extracapsular cataract extraction, the incision needs to be 10 to 12 mm for safe delivery of nucleus. In manual small incision cataract surgery (MSICS) it is between 5.5 and 7 mm and in instrumental phaco it varies from 3 mm to 6 mm 4depending on the technique and implant. The use of smaller incision with advantages of faster rehabilitation, less astigmatism and better postoperative vision without spectacles led to phacoemulsification becoming the preferred technique where resources are available.
Despite excellent facilities and skilled surgeons, the poor in the developing world and even deprived of the visual benefits on the IOL because of their inability to afford them. With this background phacoemulsification with all its benefits may not be an affordable technique due to the cost involved in the developing countries. Alternatively manual SICS with its relatively smaller incision has similar advantages to phacoemulsification and is affordable.
Manual SICS has evolved as an effective alternative to phacoemulsification in the present times. Recent studies have proved that Manual SICS is cost-effective and has more benefits than conventional ECCE. To list a few of them are as follows:
  • Better and early wound stability
  • Less postoperative inflammation
  • Can avoid suture and suture related complications (e.g. iris prolapse, suture infiltrate, bleeding)
  • Less postoperative visits
  • Early reduction and stability of surgically induced astigmatism.
Moreover, manual SICS can be performed in almost all type of cataracts in contrast to phacoemulsification where case selection is extremely important for an average surgeon. The duration of surgery and phaco power varies with the nucleus density, as also the incidence of intraocular complications, whereas in manual SICS, the time spent on nucleus delivery does not vary from case to case. In cataracts with dense nuclei, with the incision enlarged to 7 mm, the nucleus cannot delivered with an irrigating vectis. An alternative technique for extraction through a smaller wound is phacosandwich technique. This is a bimanual technique where under the cover of viscoelastics the nucleus is delivered bimanually with a vectis and Sinskey hook. Phacofracture is another technique used in manual SICS to bring out nuclei of varying grades through a smaller tunnel up to 4 or 5 mm.
Hypermature cataracts with liquefied cortex hard nuclei can get excellent results with manual SICS. To handle hypermature cataracts is phaco becomes difficult because of the fibrosed capsule, weak zonules, hard mobile, etc. Again traumatic cataract following penetrating trauma, colobomas, cataract following RD surgery, etc. are better tackled by this procedure.
Capsulorhexis is mandatory for phaco but manual SICS can also be done with the can opener technique. In a study where the learning curve in residents learning phaco was analyzed four patients had to convert to extracapsular cataract extraction and in three patients the reason for ‘bailing out’ was the absence of an intact rhexis. In MSICS the conversion to ECCE due to an absence of capsulorhexis is not necessary as the nucleus is delivered comfortably even with a can opener capsulotomy.
Incidence of intraoperative complications like posterior capsule rupture is less common in MSICS has compared to phaco. Yet another recent study compared the safety of ECCE, MSICS and phaco and reported a lower intraoperative and immediate postoperative complications in the MSICS group when compared with rest. Certain phaco related complications such as corneal burns due to the phaco probe and iris chaffing are not encountered in manual SICS. The endothelial cell counts in this subgroup of patients are no different from those who have had phacoemulsification. Endothelial cell loss in phaco depends on the density of the nucleus in contrast to manual SICS where the skill of the surgeon plays an important role.
Published evidence points out that surgically induced astigmatism following ECCE is 3.91 times higher than MSICS. Their results show that the difference in surgically induced astigmatism between MSICS and phaco with rigid IOL was not statistically significant. Implantation of foldable IOL though a standard procedure in the developed countries, is used only among the affluent society in developing countries. This is because of foldable IOL costs as much as 10 times as that of a rigid IOL. The final visual acuity between these two groups is also comparable. Our own data shows that the final postoperative visual acuity in both MSICS and phaco are similar.
Surgical time in phacoemulsification is dependent on the type of cataract. In a study performed in a rural eye camp in India manual SICS was performed within 3.8 to 4.2 minutes. Being a faster procedure, manual SICS can be performed in a high volume set up. In an Indian study where cost comparison between the two procedures was done, the average cost for the provider was US$ 16.82 for ECCE and US$ 16.68 for SICS. Both these surgeries are thus economical. Yet another study points out the cost to be US $ 17 for ECCE, US$ 18 for MSICS and US$ 32 for phacoemulsification. Though the provider cost are similarly for MSICS and ECCE, Patient's costs might be lower for SICS patients 5considering the fewer postoperative medications, follow-up visit spectacles and the total cost may thus work out to be more economically. Another major advantage of manual SICS is that, it is not a machine dominated procedure. The surgical skills and experience of the surgeon play a significant role in the results. Also considerable expense in acquiring and maintaining a machine is not required.
Transition to phacoemulsification is easier if one has mastered Manual SICS, as he is familiar with steps such as sclera pocket incisions, capsulorhexis, hydroprocedures, etc. Familiarity with these steps helps reduce the incidence of complications while learning phaco. There are instances where we have to convert from phacoemulsification to extracapsular cataract surgery. One study reports the conversion rate from phaco to extracapsular by an experienced surgeon to be 3.7%. Converting to an extracapsular result in a larger, unstable wound than manual SICS. If one is familiar with the manual nucleus delivery techniques with the self-sealing wound one can reduce suture induced astigmatism and other complications.
Phacoemulsification being an expensive technique cannot be employed as the standard procedure in developing countries with a cataract backlog and is a strain on the economy. High quality, high volume cataract surgery has been popularized in eye care centers in India to effectively manage the large backlog of cataract blindness.
In an era advances are linked to expensive innovative technology, it is exciting to witness the evolution of simplified, low cost alternatives. Manual small incision cataract surgery offers the smaller incision size of phacoemulsification and the added advantage of not requiring expensive equipment. Manual SICS offer all the merits of phacoemulsification with the added advantages of having wider applicability, better safety, with shorter learning curve and lower cost.
 
ADVANTAGES OF MSICS
  • Small incision 2.5-5 mm—sutureless
  • Low cost of lens implantation
  • Short duration surgery
  • Faster turn around for high volume
  • Low cost in term of equipments
  • Successful visual recovery in almost 100% cases
  • Can be done in all types of cataracts specially dense cataracts.
 
DISADVANTAGES OF MSICS
  • Requires larger incision than Phaco and Microphaco resulting in more post operative induced astigmatism
  • High tech foldable lenses cannot be implanted
  • Not suitable for Keratorefractive surgery.
International Society of Manual Small Incision Cataract Surgery (ISMSICS) under the leadership of Dr. Amulya Sahu is pioneer in the propagation of science of MSICS at an international level. ISMSICS has organized four international conferences on MSICS in various Asian countries where live surgery and skill transfer course were conducted on the various techniques of MSICS in an effective way. ISMSICS has also recognized various MSICS training centres in India and abroad for the practical training of MSICS techniques for beginners.
 
CONCLUSION
Manual small incision cataract surgery is safe, reliable, most affordable and less time consuming, high volume surgery with excellent visual results and minimal complications. I recommend to even those eye surgeons who are dong 100% phaco may encounter cases of rockhard cataracts and intraoperative phaco complications which can be certainly better managed by manual SICS. MSICS is better alternative to high cost instrumental phaco with similar results.