MANUAL SMALL INCISION CATARACT SURGERY

Manual small incision cataract surgery (SICS) is
becoming very popular because of its merits over
conventional ECCE as well as phacoemulsification
technique highlighted above. In this technique ECCE
with intraocular lens implantation is performed
through a sutureless self-sealing valvular sclerocorneo
tunnel incision.

Surgical steps of manual SICS are (Fig. 8.19) :
1. Superior rectus (bridle) suture is passed to fix the
eye in downward gaze (Fig. 8.19A). This is specifically
important in manual SICS where in addition to fixation
of globe, it also provides a countertraction force
during delivery of nucleus and epinucleus.
2. Conjunctival flap and exposure of sclera (Fig.
8.19B). A small fornix based conjunctival flap is made
with the help of sharp-tipped scissors along the
limbus from 10 to 2 O’clock positions. Conjunctiva
and the Tenon's capsule are dissected, seperated from
the underlying sclera and retracted to expose about 4
mm strip of sclera along the entire incision length.
3. Haemostasis is achieved by applying gentle and
just adequate wet field cautery.
4. Sclero-corneal tunnel incision. A self-sealing
sclero-corneal tunnel incision is made in manual SICS.
It consists of following components:
i. External scleral incision. A one-third to halfthickness
external scleral groove is made about
1.5 to 2mm behind the limbus. It varies from 5.5
mm to 7.5 mm in length depending upon the
hardness of nucleus. It may be straight, frown
shaped or chevron in configuration (Figs. 18.19C,
D & E).
ii. Sclero-corneal tunnel. It is made with the help of
a crescent knife. It usually extends 1-1.5 mm into
the clear cornea (Fig. 8.19F).
iii. Internal corneal incision. It is made with the
help of a sharp 3.2 mm angled keratome
(Fig. 8.19G).
5. Side-port entry of about 1.5-mm valvular corneal
incision is made at 9 o'clock position (Fig. 8.19H).
This helps in aspiration of the sub-incisional cortex
and deepening the anterior chamber at the end of
surgery.
6. Anterior capsulotomy. As described in
conventional ECCE, the capsulotomy in manual SICS
can be either a canopner, or envelope or CCC.
However, a large sized CCC is preferred (Fig. 8.19I).
7. Hydrodissection. As described in ECCE
hydrodissection (Fig. 8.19J) is essential to separate
corticonuclear mass from the posterior capsule in
SICS.
8. Nuclear management. It consists of following
manoeuvres :
i. Prolapse of nucleus out of the capsular bag into
the anterior chamber is usually initiated during
hydrodissection and completed by rotating the
nucleus with Sinskey's hook (Fig. 8.19K).
ii. Delivery of the nucleus outside through the
corneo-scleral tunnel can be done by any of the
following methods:
Irrigating wire vectis method (Fig. 8.19L). (It is
the most commonly used method).
Blumenthal's technique,
Phacosandwitch technique,
Phacofracture technique, and
Fishhook technique.
9. Aspiration of cortex. The remaining cortex is
aspirated out using a two-way irrigation and
aspiration cannula (Fig. 8.19M) from the main incision
and/or side port entry.
10. IOL implantation. A posterior chamber IOL is
implanted in the capsular bag after filling the bag with
viscoelastic substance (Figs. 8.19N, O & P)
11. Removal of viscoelastic material is done
thoroughly from the anterior chamber and capsular
bag with the help of two-way irrigation aspiration
cannula.
12. Wound closure.The anterior chamber is deepened
with balanced salt solution / Ringer's lactate solution
injected through side port entry. This leads to self
sealing of the sclero-corneal tunnel incision due to
valve effect. Rarely a single infinity suture may be
required to seal the wound. The conjunctival flap is
reposited back and is anchored with the help of wet
field cautery