Eyeworld

EW CATARACT 78 January 2017 MSICS would be especially useful in the case of a hard brunescent cataract where there is no soft cortex and the capsule looks atrophic with white dots of metaplasia. Such advanced cataracts, admittedly, are seen less frequently in developed countries. Dr. de la O said MSICS offers surgeons similar benefits to phaco cataract surgery—non-stitch, no patch, autosealing with astigma- tism-friendly incisions. The more modern MSICS technique, credited to Sanduk Ruit, MD, Kathmandu, Nepal, involves making a sclerocor- neal tunnel small external incision with a long tunnel that leads to a larger internal incision for a trape- zoid-shaped wound. Luther Fry, MD, clinical assis- tant professor, Department of Oph- thalmology, University of Kansas Medical Center, Kansas City, Kansas, wrote in his book Clinical Practice in Small Incision Cataract Surgery that "one of the small incision manual techniques […] should be in the ar- mamentarium of every cataract sur- geon. Even those doing virtually all phaco, such as myself, will encoun- ter the occasional rock hard cataract, which is probably better managed by manual technique. Anyone doing small incision manual techniques can be assured they are performing state-of-the-art surgery for their patients with results as good as with phacoemulsification." 2 Dr. Fry told EyeWorld he still thinks that while "catarocks" can be phacoed, the time and ultrasound power's effect on the eye results in a cornea that "tells you by the next morning ECCE would have been better." Most young surgeons in the U.S., however, have not performed ECCE in residency, Dr. Fry said. Due to the prevalence of phacoemulsification in developed countries, Chen et al. wrote that the role of ECCE is "unclear." 3 A few years ago, Chen et al. published a survey of ophthalmology chiefs in the U.S. Veterans Health Administra- tion (VHA). They asked if ECCE was performed at their facility, if so, at what percentage, and if they trained residents in ECCE. The survey, sent to 88 VHA facilities, saw a 42% response rate and showed that manual ECCE was performed at 72.2% of facilities composing an average of 2.2% of cataract surgery cases. The most common reason for performing ECCE was dense cataracts. Most of the facilities that responded were training residents in general but not in ECCE techniques. Facilities that did train residents in ECCE reported the most common reason for doing so was to prepare trainees in case they ever needed to convert from phacoemulsification. "The study suggests that most VHA facilities no longer train res- idents in manual ECCE. This is a concern because the manual ECCE technique is used in more than 2% of all cataract surgeries and for selected indications," Chen et al. wrote. For further perspective, a large- scale, retrospective, consecutive case series of office-based cataract surgery in the U.S. found that 0.1% of sur- gery in more than 21,000 eyes was manual ECCE. 4 "There is a learning curve to MSICS, probably equal to that of phaco," Dr. Fry said. "Possibly sur- geons new in practice could get this experience on mission trips, as on many of these, phaco is not avail- able, and even if it were, the dense cataracts seen on mission trips are better handled by MSICS." Gerald Keener, MD, Communi- ty Eye Care of Indiana, Indianapolis, who in the late 1970s created his own manual small incision cataract surgery technique that removed a split nucleus through a 6.5 mm wound, still thinks there is a place for learning a modified small inci- sion extracapsular technique, despite the prevalence of phaco. "There are times when you get in trouble during a cataract extraction and you have to enlarge the wound, and you don't want to enlarge it to 11 mm. It's good to know how to get the nucleus of an eye without hugely enlarging the wound," he said, adding that there are often courses taught on man- ual small incision cataract surgery at some of the major ophthalmic meetings. There are also cases where a conversion from phacoemulsifica- tion might be needed after it was started. A retrospective study of 540 eyes from a center in New Delhi, In- dia, published in 1998, found that a conversion from phaco to ECCE was needed in 22 eyes (3.7% of cases). 5 Reasons included pupillary miosis, posterior capsule rupture, and long phaco time due to a hard cataract. "Optimal preoperative prepa- ration and prompt recognition of complications during phacoemulsi- fication can lead to timely conver- sion to ECCE to achieve good visual outcome," Dada et al. wrote. Dr. de la O said he usually has two surgical tables ready: one with a phaco machine and another with equipment ready for MSICS. "I do MSICS while the nurse prepares the phaco and vice versa," he said, adding that colleagues who conduct follow-up appointments with patients cannot tell if the pro- cedure was phaco or MSICS. "The results in visual acuity are the same, and it's hard to see the difference on the tunnel scar with the slit lamp weeks later as I perform a sclerocorneal incision covered by healthy conjunctiva on both cases," he said. But you don't have to wait for a difficult case to choose to perform MSICS, Dr. de la O said. "You could use it on almost any case," he said. "I have perfected the technique to the point that I feel comfortable using any type of IOL, including foldables—the preference —under topical anesthesia, [without] cautery and [without a] conjunctival flap. … I've even done it combining MIGS for glaucoma." EW References 1. Tabin G, et al. Cataract surgery for the developing world. Curr Opin Ophthalmol. 2008;19:55–9. 2. Fry LL, et al. Clinical Practice in Small Incision Cataract Surgery. 2005. 3. Chen CK, et al. A survey of the current role of manual extracapsular cataract extraction. J Cataract Refract Surg. 2010;36:692–3. 4. Ianchulev T, et al. Office-based cataract surgery: Population health outcomes study of more than 21,000 cases in the United States. Ophthalmology. 2016;123:723–8. 5. Dada T, et al. Conversion from phacoemul- sification to extracapsular cataract extraction: Incidence, risk factors, and visual outcome. J Cataract Refract Surg. 1998;24:1521–4. Editors' note: Drs. de la O, Fry, and Keener have no financial interests related to their comments. Contact information de la O: drdelao@prodigy.net.mx Fry: LuFry@fryeye.com Keener: desserts83@yahoo.com MSICS continued from page 75 " You could use it on almost any case. I have perfected the technique to the point that I feel comfortable using any type of IOL … I've even done it combining MIGS for glaucoma. " –Luis de la O, MD

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