MSICS: Managing Total Bag Loss and ACIOL Placement
When performing Manual Small-Incision Cataract Surgery (MSICS) on a dense white cataract, the presence of severe, undetected zonulopathy can lead to the most significant of intraoperative surprises: the delivery of the entire capsular bag along with the nucleus. Once the vitreous baseline is stabilized with a thorough anterior vitrectomy, the surgeon must decide on the best method for visual rehabilitation.
While modern trends often lean toward scleral-fixated posterior chamber IOLs, implanting an Anterior Chamber IOL (ACIOL) remains a reasonable, evidence-based choice, especially in the setting of MSICS with a large incision. A well-sized, modern Kelman-style ACIOL is a “time-tested” solution that avoids the prolonged surgical time and technical complexity of scleral suturing or flanged techniques. In cases of profound zonular loss where no capsular support remains, an ACIOL provides excellent visual outcomes with a lower risk of long-term tilt or decentration compared to complex posterior fixations. As long as there is adequate peripheral iris support and the corneal endothelium is protected, the ACIOL is a safe, efficient, and perfectly appropriate anatomical solution for the patient. Just make sure you understand how to do ACIOL calculations and also how to correctly position it.
What do you think about using an ACIOL? Please comment below.
