Basic Manual

Small Incision Cataract Surgery

Dr. Cok I Dewiyani, Sp.M
This sutureless ECCE procedure requires
careful and precise surgery.

It is ideal for situations
high volume is needed in an environment of extreme need
without high-tech instrumentation but with minimal
compromise in quality

Sutureless ECCE features:
Maintained anterior chamber
Quiet post operative appearance and clear cornea
Early visual rehabilitation
No need for sutures to maintain post op integrity
No sutures to induce astigmatism or irritate and
cause potential site for infection
Less worry in follow up

PREOPERATIVE ASSESSMENT
OF A PATIENT FOR SICS
Similar with other cataract extraction
Identification of certain factors which are likely to
modify the procedure
Exclude patients with certain risk factors in the
initial phase
As experience and confidence is built up, more
cases are likely to fit the inclusion criteria.
Prepare
A good endothelial count,
Well dilating pupil,
Intact zonular apparatus and
Normal IOP required to perform this procedure
safely.
Anesthesia
Peribulbar block
Subconjunctival infiltration
Subtenon infiltration
Lidocaine 2%

Steps for BM SICS
Conjunctival dissection
Wet field cautery preferred

Dry carefully before scleral
dissection


SCLEROCORNEAL POCKET
TUNNEL INCISION
Wound construction is of vital importance

The ultimate outcome and ease of delivering the
nucleus are depend on wound architecture

There are two aspects we must consider
The self sealing nature of the wound
the induced astigmatism.
The dimension of the wound depends upon the
preoperative assessment of the nucleus size
and the technique used to deliver the nucleus

There are two types of external incisions in
vogue today.
The frown incision
The straight scratch incision

Hence it should be made
large enough to
accommodate the nucleus
or the implant.
Generally an 8-9 mm
inner lip suffices.
Construction of Tunnel
A - AC maintainer;
D - Sideport;
E - External incision;
C - Crescent knife;
P - Sidepocket;
1,2,3 - direction of movement of knife
Scleral incision
With crescent knife and fine toothed forceps hold
limbal tissue and create 7 to 7.5 mm frown incision
1.5 to 2 mm from limbus at apex of the frown
Initially it may be easier to make a simple linear
incision
Too deep can easily result in
premature entry
Too shallow is easily fixed
with new tunnel plane!
Sweep to each side to create an 8
to 8.5 mm internal opening
Tunnel size can be titrated to the
anticipated size of the nucleus
Paracentesis at 9 oclock
with 15 deg blade
CAPSULAR OPENING
made after the tunnel has been fashioned
This can be via a side port before actual entry
into the anterior chamber from the main wound
Or after the AC has been entered, depending
upon the technique and type of capsular
opening used.
Before Capsulotomy
Use of dye : Trypan Blue (for the beginner) + 2
minutes Remove
Insert Viscoelastin to maintain AC
Three types of capsular openings are
commonly used

Curvilinear capsulorrhexis (CCC)
Can opener capsulotomy
the envelope capsulotomy.
Internal Incision
Created after the capsulotomy
A sharp angled 3.2 mm
keratome is slid into the tunnel with a slight side
to side
movement to prevent premature perforation
Construction Of Internal Incision
A - AC maintainer;
K- 3.2mm Kerotome;
P - pockets;
I - internal incision;
4- direction of movement
Keratome entry at anterior most
extent of scleral tunnel
Sweep keratome left and right floating in
the tunnel to fully open. If done well,
chamber is maintained.
A
B
C D
Careful 8 to 8.5mm can opener capsulotomy
after filling AC with viscoelastic of choice. CCC
may be done for softer nucleus.
Hydroprocedures
The aim of hydroprocedures reduce the
nucleus size down to the smallest core

This facilitates free rotation of the nucleus in the
bag and its prolapse into the AC

Free rotation success
Carried out with a 1-2 cc syringe

The cannula may be 26-30 G in size, suitably
angled and must have a smooth rounded tip

Always check the patency of the cannula

Hydrodissection refers to the almost
complete dissection of the corticonuclear
A B
C
D
With capsulotomy needle inserted into
nucleus, rock and roll twisting up and
releasing the nucleus from the capsular bag
Hydrodelineation, also known as
hydrodelamination and hydrodemarcation

refers to the separation of epinucleus from the
nucleus by a fluid wave between the two

It is performed with the same instruments as in
hydrodissection.
Hydrodelineation

C - Cortex;
N - Nucleus;
E - Epinucleus;
GR - Golden Ring
Insufficient hydrodissection is the most
common complication which makes
subsequent manipulation of the nucleus
difficult and provokes excess strain on the
capsule and the zonules.
Nucleus Management
The equator of the
nucleus is prolapsed
out of the capsular
bag
The whole nucleus
is delivered into the
anterior chamber.
The whole nucleus
is delivered out of
the anterior
chamber taking care
to avoid injury to the
endothelium.
Many surgeons prefer to reduce the size of
nucleus to keep the incision size the smallest
possible.
All these procedures are visco-dependent and
demand a high degree of skill.
Techniques :
The wire snare
pre-chopper
The phaco-fragmentome or nucleotome technique
Phacofracture technique


Phaco Fragmentation
N-Nucleus; P-phaco-fragmentome;
S-spatula; B-Blade; I-Incision;
1,2,3,4 - Nuclear fragments
With lens loop or vectis depress posterior lip of scleral
tunnel and allow nucleus to glide out through the incision
(must be large enough)
NUCLEUS DELIVERY
The nucleus may be delivered out of the AC by
either

hydro-expression,
visco-expression,
vectis assisted delivery,
or the fish-hook technique.
NUCLEUS DELIVERY
A - AC Maintainer; P-Side pocket;
E-epinucleus; N-nucleus; C-Cortex;
G-Glide; 1,2 - Egress of the nucleus
EPINUCLEAR AND CORTICAL
REMOVAL
The epinucleus in the AC is removed by stroking
the scleral lip while the AC maintainer is on

Epinucleus in the bag is manipulated out with a
Sinskey hook or iris spatula and then flushed
out.
Gently depress post. lip of tunnel to milk out
remaining lens material while tilting the
globe by holding the limbus at 6 oclock
Cortical removal is by automated aspiration or
manual aspiration

Automated aspiration has distinct advantages,
but has a learning curve
Manual I/A has the advantage of flexibility, easy
learning, safety margin and better surgeon
control.
Bimanual I/A through two side ports is the ideal
method of performing I/A with a closed chamber
from a collapsed tunnel.

Automated Irrigation / Aspiration
J-shaped cannula for I/A of
subincisional cortex
Side port Simcoe aspiration offers the
advantage of a better approach to the sub-
incisional area besides a closed deep chamber

Iris massage maneuver to loosen cortex and
bring it to the centre (though this invariably
damages the iris)
ice-cream scoop maneuver (turning the
Simcoe tip anteriorly and towards the middle
while aspirating cortex)

the post IOL implantation aspiration (rotation
360 of a PCIOL with a dialler after insertion to
loosen cortex, mobilize it and facilitate
aspiration).
In the presence of a posterior capsular tear, the
flow and aspiration pressure must be reduced

Ideal technique is the dry technique under
viscoelastic

Vitrectomy is required if air injected into the AC
is not freely mobile.
IOL IMPLANTATION
The most commonly implanted IOL the rigid
6-6.5 mm optic sized IOL

If the tunnel width is less (5.5 mm) enlarge

Attempting to push an IOL through an
insufficient incision corneal trauma and may
damage the self sealing nature of the tunnel
The IOL holding forceps should preferably have
a curve (Shepards or Kratz forceps) to negotiate
the tunnel, which has an entry 1.5-2 mm
posterior to limbus

The capsular bag should be inflated with
viscoelastic or kept open by fluid from a AC
maintainer
Insert IOL and remove methylcellulose. Inject
BSS to moderate pressure. AC should remain
formed. No conj closure needed.
The area adjacent to the tunnel is cleared of
debris and blood to prevent these from being
carried into the AC with the IOL

The IOL of the correct power is held
longitudinally by the forceps and manipulated
through the tunnel into the AC.
The IOL is held tilted upwards
at the time the leading haptic
is being introduced into the
tunnel
As the haptic enters the AC, the lens is
made horizontal and gently pushed
inside
Once the leading haptic reaches the 6
oclock margin of the capsulorrhexis, the
IOL is tilted slightly downwards to make the
leading haptic pass under the rhexis
margin
A Sinskey hook or a lens manipulator is
used to maneuver the IOL into the bag
In the event of a PC rupture, the decisio implant
an IOL is based on the extent of capsular
support available

After IOL insertion remove viscoelastic from
the AC

Viscoelastic behind the IOL is removed by lifting
the IOL slightly with the I/A cannula.
Wound Closure
No suture is required if the tunnel has been well
fashioned (5.5 mm to 6.5 mm)

The integrity of closure can be checked by
applying gentle pressure on the eye
observing for the egress of fluid
or by injecting a small amount of BSS from the side port and
observing the deepening of the chamber

The side ports are hydrosealed
Complete the operation with routine
antibiotics and remove the speculum,
drapes, clean and patch the eye.
If a suture is required, an infinity suture is applied

The area is then covered by conjunctiva

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