Older Surgical Techniques Still Matter

Yes, I love phaco too, but we should all learn to do SICS as well(Classic ECCE teaching video below)

This incision is not leaking, so why suture it? For an increased measure of safety in this particular case, but also so that the young surgeon-in-training becomes proficient in this skill. I like to say that no one was born knowing how to suture with 10-0 nylon; it is a skill that must be practiced and learned.

Ophthalmology is a constantly evolving specialty, particularly with regards to procedures such as cataract surgery. And while we are always striving to learn new techniques and technologies to provide better visual outcomes for our patients, it is important for us to know and understand the older methods, instruments and history of ocular surgery.

When I was a young ophthalmology resident, our training program started by teaching us cataract surgery with the manual (non-phaco) technique using a large incisions and direct removal of the entire, intact cataract nucleus. This was followed by lots of suturing to close the incision and then weeks to months of recovery for our patients. Since these patients started off with severe cataracts and count-fingers vision, they were very happy. But I was anxious to start learning phaco and working with smaller incisions to give patients faster recovery and better vision. An admired mentor, Brad Straatsma MD, explained to me that it was important to know and understand the older surgical techniques before moving on to the newer methods of cataract surgery.

With the advent of ultrasonic phacoemulsification and foldable lens implants, it may seem logical to abandon the manual technique of extracapsular cataract surgery, which is typically done with a larger incision that requires sutures for closure. But there is utility in knowing how to perform a manual extracapsular surgery, such as for the patient with a very dense brunescent cataract in the presence of a weak corneal endothelium. In this case, every effort to preserve the endothelial cells is made to avoid pseudophakic bullous keratopathy and future corneal transplantation. Sometimes during a challenging cataract case, there is a need to convert from phacoemulsification to a larger-incision extracapsular technique. In addition, studies have now shown that for the dense cataracts seen during charity surgery mission trips, manual techniques can be faster and safer than phacoemulsification.

Uday Charity

Manual, extra-capsular cataract surgery has evolved significantly. Gone are the corneo-scleral scissors and leaky incisions requiring many sutures. Now we have incorporated the SICS (Small Incision Cataract Surgery) procedure into our teaching at UCLA. The technique of SICS that I learned is from my colleagues in India who have done many millions of surgeries this way. I even met multiple surgeons who have personally done 100,000 cataract surgeries in their careers and who routinely do about 100 procedures in a single day. These expert Indian SICS surgeons are my teachers and I am their student.  Dr. Sanduk Ruit has been instrumental in advancing this technique across the globe as well. There is such a huge worldwide need for SICS surgery to help cataract patients.

Learning these procedures also benefits surgeons because it helps them to develop skill sets, such as fine suturing ability, that they would not ordinarily use with less invasive procedures. Placing sutures to seal an extracapsular incision in an astigmatically neutral way is not easy, and it is a skill that some younger surgeons are lacking. To address this, I require my ophthalmology residents to throw many sutures in the wet lab before suturing in the operating room.

In the past decade, I have only rarely found it necessary to perform a manual extracapsular cataract surgery. However, in my teaching role, I have made sure that every one of physicians whom I have trained has learned and performed at least a few of these manual surgeries. This applies to surgeons-in-training here in the USA as well as across the globe in the many different countries that I have visited. This photo is from a trip to Việt Nam in 2006 at the first Imperial City Eye Meeting

Uday Vietnam

The teaching video for today shows a technique of manual, extra-capsular cataract surgery 10 years ago by one of my former ophthalmology residents, Alex Yuan, MD, PhD, a very talented surgeon who now specializes in vitreo-retinal surgery.

There is a lot to learn from the video and even though it is recorded in an older format. If you are an ophthalmology resident, make sure that you learn this technique during your training period.

Steps shown in this manual, extra-capsular cataract surgery video:

  1. paracentesis made and capsule stained with trypan blue dye
  2. anterior chamber filled with dispersive viscoelastic
  3. conjunctival peritomy, hemostasis with cautery
  4. half-depth scleral groove and incision shelf creation with crescent blade
  5. anterior chamber entered with keratome
  6. sufficiently-large capsulorhexis performed
  7. cataract nucleus prolapsed into anterior chamber
  8. incision opened to full shelf width
  9. cataract nucleus expressed from the eye
  10. single incision placed in the incision
  11. irrigation & aspiration performed to remove lens cortex
  12. capsular bag filled with cohesive viscoelastic
  13. IOL inserted into capsular bag
  14. viscoelastic evacuated from anterior segment
  15. incision sutured closed and then conjunctiva closed over it



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