A Place For Manuel Small Incision Cataract Surgery In Europe - What I Brought With Me From Training In India

Manual small-incision cataract surgery (MSICS), represents an economical, minimally invasive and sutureless approach to extracapsular cataract extraction (ECCE). In developing regions, it is the most performed technique in cataract surgery and offers notable advantages over phacoemulsification, including a reduced surgical time, diminished reliance on technology and lower overall cost, with comparable outcomes and complication rates and a wider applicability, notably in denser cataracts. Although the second most used technique in the world, SICS remains relatively unknown to most European surgeons and is hardly discussed in training. I wish to briefly discuss the SICS technique and its use for the European cataract surgeon.

As a young ophthalmologist, I thought it useful to learn this technique in a structured setting. I did a four weeks hands-on short term course at Aravind Eye Hospital in India, one of the world leading institutes for high volume, high quality, low cost cataract surgery with more than 300 000 cataract surgeries performed per year. Overall, I performed 25 SICS procedures, in a highly structured program including theoretical classes, wetlab and simulation training sessions.

SICS can be done under retrobulbar or sub-Tenon’s block. It includes a three-plane scleral incision of 6.5 mm, followed by a sclerocorneal tunnel with side-pockets allowing for smooth nucleus removal. A continuous curvilinear capsulorhexis (CCC) is preferred but a canopener capsulotomy is also possible in SICS. The size of the CCC should be bigger than in phaco, about 7mm. This is followed by hydrodissection and prolapse of the nucleus in the anterior chamber and nucleus delivery via the scleral tunnel. Manual cortex aspiration precedes lens implantation. If well constructed, the planed scleral incision is water tight and provides a stable and self-sealing wound.

SICS could be preferable over phacoemulsification in dense cataracts, zonular weakness, small pupil, compromised corneal visibility and in CCC difficulty since a conversion to a canopener capsulotomy doesn’t compromise the following steps. Moreover, endothelial cell loss has been found to be less important with SICS, making it an interesting option in patients with low endothelial cell count, where phaco energy could be detrimental. Finally, SICS technique can be helpful in mastering scleral incisions and can be combined with a trabeculectomy. 

Each step of SICS is crucial and a properly scheduled and supervised training in this technique is needed to master it and be comfortable if a planned phacoemulsification should be converted to SICS.

SICS technique can be learned after a hands-on training in a specialized and high volume center, as offered in Aravind Eye Hospital and other centers in India. After four weeks, I left feeling well-trained in SICS. Possessing the capability to effectively perform SICS remains a valuable skill that should be complimentary to a European surgeons’ arsenal. Apart from its clear benefits in developing regions, it could have a place as well in the developed region, notably in mature cataract and challenging cases being less ideal for phacoemulsification. With proficiency in both techniques, the young cataract surgeon is better prepared to handle a diverse range of scenarios.