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Manual SICS seen as safer starting point for cataract surgeons in developing world
At Aravind Eye Hospital in India, manual SICS has a low complication rate and is a less expensive alternative to phacoemulsification.
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In the developing world, manual small-incision cataract surgery may be a safer initial procedure for inexperienced cataract surgeons to learn than phacoemulsification, according to a study.
Phacoemulsification is the standard of care in the developed world. However, it is more expensive to perform, and this has led to wider adoption of manual small-incision cataract surgery (SICS) in countries with large indigent populations.
According to study co-author David F. Chang, MD, OSN Cataract Surgery Board Member, manual SICS is not only more affordable, but in the developing world, it is easier to learn and safer in the hands of inexperienced cataract surgeons.
“Globally, of the more than 20 million people who are bilaterally blind from cataract, most live in the developing world without access to affordable surgery,” he said. “In manual SICS, we have a lower-cost procedure that can be more quickly and safely learned by the legions of new cataract surgeons that must be trained in order to impact this growing backlog of cataract blindness. This is the best solution to treat as many cataract patients as possible in countries with limited resources and eye surgeons.”
The study
The retrospective cohort study at a regional Aravind Eye Hospital in Madurai, India, included all 79,777 consecutive cataract surgeries performed over a 12-month period: 20,438 phacoemulsification procedures, 53,603 manual SICS procedures and 5,736 extracapsular cataract extraction procedures.
Surgeries were performed by staff surgeons, fellows, residents and visiting trainees. Complication rates for each type of surgery were compared between each group of surgeons.
David F. Chang
“Aravind is a unique setting because their regional hospital system performs one of the highest volumes of cataract surgery anywhere in the world — more than 200,000 annual cases,” Chang said. “Nearly 70% of their cataract volume is done on charity patients who pay virtually nothing for the surgery. And they have an outstanding electronic record system that captures very thorough, reliable and retrievable data.”
Standardized surgical protocols followed by all surgeons, regardless of experience, help the hospital to be as cost-effective and efficient as possible, he said, which also facilitates a study like this.
Looking at all surgical methods combined, the intraoperative complication rate decreased with greater surgeon experience. It was 0.79% for staff surgeons, 1.19% for fellows, 2.06% for residents and 5% for visiting trainees.
There was no statistical difference in the overall complication rate between manual SICS (1.01%) and phaco (1.11%). However, this equivalence did not hold across different levels of surgeon experience.
Among the staff surgeons, who were equally adept at both procedures, the surgical complication rates were less than 1% for each method. However, with trainees, the complication rates were 4.8% for phacoemulsification and 1.46% for manual SICS, which was a statistically significant difference (P < .001). Trainees experienced a higher rate of posterior capsular rupture and vitreous loss with phaco (3.8%) than with manual SICS (0.67%). The differences were highest among visiting trainees, who were ophthalmologists from other countries undergoing 3 months of surgical training at Aravind. For these surgeons, the complication rate with phaco was 11.2%, compared with 3.68% for manual SICS.
“This group best approximates the situation of less-experienced surgeons who must be trained to perform cataract surgery in the developing world,” Chang said.
Manual SICS vs. phacoemulsification
“Manual SICS is not a procedure for the United States,” Chang said. “Phaco with foldable IOLs minimizes the incision size and produces better and more predictable refractive outcomes.”
According to lead study author Aravind Haripriya, MD, the difference in outcomes between phacoemulsification and manual SICS can be attributed to higher astigmatism, which may be induced by manual SICS.
“Technique-wise, switching to a temporal wound in SICS addresses this to a good extent, since most patients in this age group have a steeper cornea in the horizontal meridian,” she said.
According to Haripriya, phacoemulsification is more challenging and more expertise is needed to have good outcomes with hard, mature and complicated cataract cases.
She said several advantages of the manual SICS technique include its ease of application to almost any cataract, the offering of a more predictable outcome in difficult situations, and the affordability of the procedure to lower-income patients.
“In the developing world, we need to train relatively inexperienced surgeons to do cataract surgery,” Chang said. “They are often working on their own without any supervision and without backup from vitreoretinal specialists. The critical goal is to have them first learn a procedure with which they can handle very advanced and mature cataracts with the lowest complication rate.”
As inexperienced surgeons become more skilled at intraocular surgery, they can learn phaco later, he said.
Haripriya said she believes the lower cost of manual SICS will help keep the surgical technique relevant.
“The focus in any economy is to give good outcomes to the patients following cataract surgery, and if this is possible with lower costs, surgery can reach many more people,” she said. – by Ashley Biro