Manual Shelved-Incision Cataract Surgery (MSICS) is an excellent technique for eyes with pseudoexfoliation (PXF), particularly in global health settings where advanced technology may be limited. PXF presents significant challenges, primarily due to zonular instability and poor pupillary dilation. The large incision of MSICS allows for the safe delivery of the entire nucleus out of the capsular bag and into the anterior chamber, which minimizes the mechanical stress on weakened zonules compared to the high-vacuum maneuvers of phacoemulsification. In these cases, the use of a capsular tension ring (CTR) can provide 360-degree support to the bag, but it is not always required. Furthermore, since PXF is associated with a friable iris and a non-dilating pupil, manual stretching or the use of iris hooks may be required to visualize the capsulorhexis. By maintaining a stable anterior chamber and avoiding the trampoline effect and capsular bag stress of phacoemulsification, MSICS can reduce the risk of intraoperative zonular dialysis and perhaps late-stage IOL dislocation.
