Manual small-incision cataract surgery: A technique every surgeon should learn
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Our guest today is Susan MacDonald, MD, a distinguished colleague who made the decision to devote her skills, time and efforts to the needs of underserved communities. As co-founder and president of Eye Corps, she is the leader of important projects for sustainable delivery of eye care, fighting cataract blindness in South Saharan Africa.
Here she will discuss the use of manual small-incision cataract surgery (MSICS) in low-resource settings, as well as the value of this technique as a potential alternative to phaco in other specific cases. With these thoughts in mind, Dr. MacDonald emphasizes why MSICS should become part of the surgical training of every ophthalmologist.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Manual small-incision cataract surgery, or MSICS, is a great technique that should be part of the skill set of every cataract surgeon. Our challenge is how do we become experts in this technique and how do we integrate it into our residency programs.
Let me begin with a few personal notes that I believe are important to understand my choices and my philosophy. For 25 years in the United States, I was in private practice and had a teaching position at Tufts Medical School in Massachusetts.
When I was learning cataract surgery at the Moran Eye Center, I did mostly phaco and maybe extracapsular cataract extraction a couple of times. This was what we all did in our training, and this brought up a generation of key thought leaders and ophthalmologists in the United States whose area of expertise is either phacoemulsification or even femtosecond laser-assisted cataract surgery. Very few of us had the opportunity to learn MSICS, a technique that was just being created at that time and mainly performed far away from the U.S.
And yet, MSICS is a great technique that should be part of the skill set of every cataract surgeon. It is better and safer than phaco in patients with dense cataracts, zonular problems and compromised corneas because you can remove the cataract without putting the zonules under pressure and preserve the cornea from the impact of ultrasound. In low-resource settings, MSICS allows us to provide the advantages of small-incision cataract surgery, and even refractive cataract surgery, at a fraction of the cost of phaco.
As U.S. surgeons, we do not have many opportunities to become proficient in this technique. That may create a bias because our “go-to” technique will be what we are best at. And this bias may be unintentional when we go to areas with low resources. If we can, step back and think about the unintended consequence of this preference. If we are choosing it because we are experts and do it best, we may be implying that the technique is best.
When surgeons from the United States and other countries come to volunteer in outreaches, they often assume that bringing their phaco expertise and technologies and teaching phaco surgery in those settings would be the best answer to the local needs. But there is a bias to that, and it is important for us to step back and ask ourselves if the best surgery at home is also the best in the rest of the world. If a country does not have the infrastructure to support phacoemulsification technological support, including the bioengineers that keep the equipment in good working order, this means there is no one to fix it when it breaks and no company that warrants the quick delivery of replacement parts. I am speaking from experience because I purchased a phaco machine once. We used it, but when it broke, I could not get it repaired in country. It cost me a lot of money to send it to South Africa to get it fixed. Then it got stuck in customs, and before we could get it back, 11 months had gone. If this had happened to someone who could not afford the costs involved, that phaco machine would have just stayed broken. This made me pause and think if this was really the correct solution.
In addition, if there is a complication with phaco surgery, such as a dropped nucleus into the vitreous cavity, in the United States you can quickly refer the patient for vitreoretinal surgery. If the same happens in Songea, Lindi or another region in Tanzania, there are no facilities for retinal intervention, and the patient will need to go to the capital city, which is a 10-hour bus ride, and have the money to pay for vitrectomy. There is almost no risk of nucleus drop with MSICS, and you can provide a service that is safer, has good results and is less expensive.
Last but not least, MSICS also has a much smaller carbon footprint, and it may be the right pathway to pursue for all of us. It may sound rather extreme, but we already are in a state of climate emergency and need to consider the impact of our actions.
Pearls for MSICS
My No. 1 recommendation is to use larger incisions when you begin learning MSICS. Early in my learning curve, I started out by using a large frown incision of 7.5 mm, about 1.5 mm posterior to the limbus, creating a tunneled incision 1 mm into clear cornea. I gradually learned to reduce the size of this self-sealing incision. I also leaned upon my phaco skills by creating a large capsulorrhexis.
We also have to know that things happen gently in the anterior chamber because it is not under pressure. I use a cohesive viscoelastic because once your capsulorrhexis is done and you have loosened up the nucleus, you want to be able to pop that into the anterior chamber. If you have a dispersive viscoelastic that is not going to burp out of the anterior chamber, it makes it more of a challenge and will work against you. I tip up one side of the nucleus, and then I use a needle to help rotate it up. At this stage, I protect the cornea with dispersive viscoelastic.
Fluidics are used to express the nucleus with the help of a Simcoe cannula. I gently push down on the posterior lip of the tunnel. I am patient and do not expect anything to happen fast because we want the pressure to build up and then slowly allow the nucleus to be expelled. If it gets caught in the incision, I immediately open this up a little bit.
The idea in the first 10 or 15 cases is to have success. Then, as you progress in your learning curve, you can start getting a little bit savvier with your incision, making it smaller and placing it on the steep axis to make sure you are doing more of a refractive procedure. There is a great organization called the International Society of Manual Small Incision Cataract Surgeons. If you participate in their events and group discussions and watch some of their videos, it is amazing to see how small they can make their incision and how focused they are on the refractive outcomes.
Where to learn MSICS
Bonnie Henderson, MD, president and CEO of HelpMeSee, another nonprofit organization, helped me understand that it is critical to bring MSICS into residency programs and have one or two faculty members who are comfortable with this technique. In the U.S. and around the world, there are a lot of amazing surgeons who know and can teach MSICS, and both the ASCRS and the AAO offer a variety of educational resources for those who want to know more and learn the technique. Learning opportunities are also offered by the International Society of Manual Small Incision Cataract Surgeons (https://ismsics.com/), and HelpMeSee (https://helpmesee.org/) is dedicated entirely to training.
If we are so dogmatic about phaco as the only way to do surgery, we shrink our skills. We all have had those hard cases in which phaco was not the best choice. Some may say that femto could be used in those eyes, but not everyone has a femto laser. There is nothing wrong with having more skills, using them in our surgical settings and passing them down to the younger generations.
- For more information:
- Susan MacDonald, MD, is chair of the ASCRS Foundation, which delivers humanitarian eye care and physician education both nationally and internationally, and CEO of Eye Corps, which supplies equipment, education and mentorship to equip Tanzanian doctors to reduce cataract blindness and other surgical eye diseases. She can be reached at susanmacdonaldeyecorps@gmail.com.
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