An entire journal issue devoted to small incision cataract surgery (SICS) is testimony
to the popularity of the technique. Although the editor probably intended a perspective
on manual SICS (MSICS), a brief background might justify my wider viewpoint. Having
learnt the technique of MSICS 17 years ago, facilitated by Michael Blumenthal, I learnt
the other SICS technique, phacoemulsification, formally from Kenneth Spitzer in 1992.
I ensured that both techniques, MSICS (1992) and phacoemulsification (1994), became
routine for all residents (and faculty) in my residency program. Accordingly, although
I have popularized MSICS around the country, I will take a broader outlook and comment
on several aspects of SICS, not just MSICS.
Until recently, MSICS was considered as a low-tech, unproven poor cousin to the gold
standard phacoemulsification. Several recent articles have compared MSICS to phacoemulsification
and demonstrated almost equivalent outcomes.[2–4] The proven advantage of phacoemulsification
is a statistically significant benefit in induced astigmatism of about 0.4 diopter
(D); the clinical significance of this statistically significant difference is however
5] On the other hand, nucleus drop with phacoemulsification (0.9%) has a higher relative
risk compared with MSICS (Thomas R, unpublished data). Moreover, how much ever
we may espouse providing the gold standard for the entire cataract population, in
reality even if that were desirable, “phacoemulsification for all” (cataracts) in
India (or for that matter anywhere) is neither practical nor feasible. The advantages
of MSICS as a low-cost “equally effective” technique makes it an alternative, especially
in an unequally developed country like ours.
It is argued that MSICS is worse for the endothelium, but a formal study showed no
difference in endothelial cell loss between MSICS and phacoemulsification. This
is however likely related to the technique of MSICS. There are several types of MSICS,
some of these being more elegant and sound in principle than others. I am partial
to the Blumenthal technique of MSICS because of the philosophy of the technique as
well as that of the anterior chamber maintainer (ACM) integral to this method.
The ACM keeps the chamber formed (and endothelium protected) during all the steps
of the surgery; other MSICS techniques are unlikely to be equivalent in this respect.
The ACM also makes cortex aspiration easier and safer; and if an aspirating cannula
is used on a syringe without the plunger, capsule vacuuming can be safely performed
without expensive “cap-vac” software. What's more, the ACM converts cataract surgery
into an “egress” system, much like vitrectomy (a procedure with a low endophthalmitis
rate). It is my bias that such an “egress” system decreases the endophthalmitis rate
in cataract surgery too. In fact, I have always used the ACM for phacoemulsification
too. It especially makes teaching very much easier and safer, permitting focus on
the “phaco” steps rather than things like foot positions. Moreover, the ACM continues
to cleave planes created by hydrodissection (even if incomplete). Also, the aspirated
fluid is replaced immediately, obviating reliance on expensive software to decrease
fluctuations and surges: it literally converts a low-end phacoemulsification machine
into a high-end model. Finally, if one wants to learn microincision cataract surgery,
an ACM allows that almost without a learning curve.
There are those who argue vehemently for MSICS, while others perceive phacoemulsification
as the only way. Is there a reason for “phaco” surgeons to learn MSICS too? 100% phacoemulsification
(like 100% anything else) is not possible. Even the most experienced phaco surgeons
need to “bail out” sometimes, even if it is only due to machine failure. The published
literature from India documents this occurrence as 3.7%, about one in 25. Phacoemulsification
converted to an unplanned standard extracapsular (ECLX) surgery is worse than a planned
ECLX; conversion to MSICS, usually utilizing the same wound, provides better outcomes.
Surely, we do not espouse the training of surgeons in phacoemulsification only, as
is the current trend in developed countries. Such a surgeon “bailing out” of phacoemulsification
would be “bailing out” into tiger country, without a parachute.
Similarly, there are reasons for MSICS advocates to learn phacoemulsification. Many
patients demand phacoemulsification and are willing to pay more for it, permitting
sustainability, in all settings. Even if we strongly believe a particular case is
better suited for MSICS, our decision is more likely to be accepted if made from the
position of skill in both methods. Rather than supporting only phacoemulsification
courses, industry too might be advised to take the broader view and sponsor teaching
of cataract surgery per se, including MSICS. After all, those who learn MSICS today
are the ones who will want to learn phacoemulsification tomorrow; they are tomorrow's
market. The only skills left to acquire will be the actual “phaco” steps, which MSICS
surgeons can attain more easily.
Therefore, MSICS is really not so much an “alternative” but can be an additional technique
in our armamentarium. This armamentarium also includes the standard ECLX as well as
the now-forgotten intracapsular surgery. Each technique is used according to the case
encountered, the setting, as well as the surgeon's skill and comfort level. A (now
rare) hypermature, subluxated lens suspended by only a quadrant of zonules might require
intracapsular surgery; alternatively, there is a MSICS technique to glide such a nucleus
out too, if the surgeon were comfortable with that. Others may have the skill to perform
phacoemulsification in such a case: as long as it does not cost much (which it does)
and is not much more likely to involve a vitreoretinal intervention (which it is),
because the end result is unlikely to be different.
I feel that this issue of the journal on MSICS would have benefited from an article
on the teaching of surgical skills and techniques. There are some basic requirements
for the transfer of cataract surgical skills: “one-on-one” teaching by an experienced
surgeon using high-quality microscopes (with beam-splitters and assistant scopes),
as well as instrumentation (and attitude) to manage complications in the most modern
manner; the goal is to obtain the best outcome possible under the teaching circumstances.
Anything less is a travesty.
Although I learnt MSICS unsupervised (because there was no alternative and it was
essentially an extension of ECLX), phacoemulsification, was an entirely different
technique that I considered unsafe to learn without expert help. The accompanying
editorial recommends the model that we were using 15 years ago, wherein the surgeon
was taught in his own environment. In this day and age, with the abundance of
SICS courses and trained surgeons, there is really no excuse for unsupervised learning
of a potentially dangerous technique like phacoemulsification (or for that matter,
MSICS), while placing the patient at (avoidable) risk. Still worse is to be instructed
in phacoemulsification by an industry engineer, no doubt skilled in machine nuances
and armed with the theoretical knowledge of the procedure, but without the ability
to safely train an ophthalmologist. Industry must forbid their engineers from such
Actually, the profusion of SICS courses is a sad testimony to the state of our residency
programs. Surely, the next generation of ophthalmologists should at least be adequately
trained in modern cataract surgery and not have to seek courses or fellowships to
achieve this. Modern cataract surgery does not mean just the steps of the surgery.
Residents will do whatever they observe their teachers do. If they are exposed to
shoddy routines, like not scrubbing between cases, sharing of instruments, and general
lack of respect for sterile operating room procedures (all of which constitute an
unfortunate, reckless attitude), whether in the setting of residency programs, camps,
or SICS courses, it will only serve to spawn and reinforce bad habits. The process
will ruin our generation next and place their patients at risk.
We are already witnessing the negative impact. It seems that some colleagues do not
sterilize the phaco tips (let alone hand pieces) between cases. With the risk of not
just endophthalmitis, but in these days, HIV and hepatitis B too, this practice is
extremely irresponsible and worse than negligence. Let us be reasonable. If you want
to perform a high-tech technique like phacoemulsification, please understand that
the machine, handpieces, disposables, and the procedure are going to be relatively
expensive. Accept it. Cutting costs on sterilization and safety is not the answer
to the perceived need for high volumes, not with any technique. If economization is
required, economize elsewhere, or use a procedure like MSICS that does not require
expensive instrumentation, and that does not mean that such appalling shortcuts are
permissible with the cheaper MSICS. Industry too should also discharge their responsibility
(and avoid potential problems for themselves) by proactively educating their customers
about sterilization requirements for their machines and accessories.
To conclude, there is a welcome trend towards SICS in our country. Both MSICS and
the “other” SICS have a place in our armamentarium and are complementary, and both
are here to stay. Supervised, responsible teaching of SICS techniques is the need
of the hour, which is the primary responsibility of residency programs; courses and
fellowships, although important, are “band-aid” measures that can do only so much.