Eyeworld

EW CATARACT 26 December 2018 by Liz Hillman EyeWorld Senior Staff Writer Experts agree that manual small incision cataract surgery has a role in regular practice and training programs, even in developed countries W hile phacoemulsifica- tion has been the gold standard of cataract surgery for decades, a low tech procedure— manual small incision cataract surgery (MSICS)—has carved out a place for itself, especially in devel- oping countries where phaco is not as readily available. However, some think there is a place for it in the U.S. as well. "I use MSICS as a planned primary procedure in my own practice several times each year," said David F. Chang, MD, clinical professor, University of California, San Francisco. "It is sometimes safer than phaco for the most advanced, ultrabrunescent cataract, particu- larly when comorbidities, such as phacodonesis, corneal endothelial dystrophy, or pupillary membranes and synechia, are present." For similar reasons, Julie Schallhorn, MD, assistant profes- sor of ophthalmology, University of California, San Francisco, and Matthew Oliva, MD, Medical Eye Center, Medford, Oregon, think MSICS should be incorporated into residency training programs, even if phaco is the most common course of cataract surgery. "I think it is critical that res- idents learn to make self-sealing scleral tunnel incisions and un- derstand how to deliver a nucleus manually," Dr. Oliva said. "This is a critically necessary skill in cases with a zonulopathy or if a phaco case is going poorly. I routinely do MSICS in my clinical practice several times a month for dense or unusual cataracts. The corneal endothelium does much better with MSICS than phaco in rock hard cataracts." In addition to finding it valu- able in dense cataract cases, Dr. Schallhorn pointed out that MSICS combines many surgical techniques that are important for any anterior segment surgeon to know. "For this reason, we start residents with MSICS as their first YES connect cataract surgeries as primary surgeon in the first year of residency. We begin the year with an intensive, week-long wet lab introduction to microsurgery and MSICS," Dr. Schallhorn said. There is a bit of a learning curve to MSICS, Dr. Chang said, but it's less steep for surgeons who have al- ready learned large incision manual extracapsular cataract extraction. "Large incision manual ECCE should ideally be a part of every- one's surgical armamentarium," Dr. Chang said, explaining how it can be used with extreme zonulopathy, a zonular dialysis, or converting from phaco following a presumed posterior capsular rupture. "When converting from phaco, one can abandon the phaco incision and make a traditional large limbal in- cision superiorly," he added. "With a soft eye, it is difficult to make the large scleral pocket incision that is required for MSICS." However, most residents aren't learning ECCE nowadays. 1 Dr. Schallhorn, for example, said she only learned MSICS in residency and it is the only extracapsular cata- ract surgery that she performs. "The major difference between these two procedures is the incision size and structure. With MSICS, you create a 'frown' scleral tunnel inci- sion size that is often times self-seal- ing," Dr. Schallhorn said. "During nuclear delivery, the lens will mold to fit the incision. With traditional extracap, the incision is more ante- rior and much larger, exposing the eye to longer periods of hypotony and requiring multiple sutures for closure." Regarding the learning curve, Lynds et al. performed a retro- spective case series looking at the outcomes of resident MSICS at a Dallas hospital. 2 The investigators concluded that the learning curve appeared most tied to the wound construction, but the procedure was safe and efficacious on the whole. "With several advantages over phacoemulsification, such as cost and ability to remove very dense nuclei, manual SICS will play a valu- able role in cataract surgery," Lynds et al. wrote. How to perform MSICS Dr. Oliva's first piece of advice for learning MSICS is to work with an experienced MSICS practitioner who can step into the case if needed. Start with easy cases, those with good exposure, dilation, and mature cataracts, avoiding micropupils, loose zonules, and pseudoexfoli- ation cases early in the learning curve. "One of the challenges of MSICS for the beginning surgeon is that complications to the eye can be quite severe," Dr. Oliva said. For example, poor wound construction can lead to Descemet's detachment or iris trauma. Another pearl he offered is to grasp the eye just lateral and poste- rior to the wound edge—rather than grasping the wound itself—and ro- tate it downward with 0.12 forceps. For the wound, Dr. Chang constructs an 8-mm temporal scleral MSICS and its place in the hands of young eye surgeons M ost ophthalmology residency programs do an excellent job teaching residents modern cata- ract surgery. Trainees are getting more and more exposure to the latest technologies and techniques including the femtosecond laser, iris expansion devices, specialty intraocular lenses, etc. While staying cutting edge is important for any young surgeon, it is also important to know how to deal with complications and how to handle unique situations. In some circumstances, MSICS can be a safer way to remove a cataract, and residency or fellowship is the perfect time to tackle challenging cases with the supervision of an attending surgeon. I strongly recommend young surgeons make it a priority to learn MSICS, especially if they are interested in serving abroad in developing countries at some point in their career. Another benefit of learning MSICS is that it can help hone other skills such as creation of a self-sealing scleral tunnel incision. In this month's "YES connect" column, we discuss MSICS with experts in the field and share the importance of learning this surgery. I hope that after reading this article, you will consider making it a priority to learn MSICS. Samuel Lee, MD, YES connect co-editor A preoperative black lens with posterior synechiae, shallow anterior chamber in a 60-year- old patient with retinopathy of prematurity

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