The first manual small incision cataract surgery (MSICS) case is a true rite of passage for any resident. Unlike phacoemulsification, MSICS requires a deep understanding of scleral architecture and fluidics without the assistance of a machine. The challenge begins with the construction of the self-sealing scleral tunnel. As a beginner, your goal is to maintain a consistent depth: too shallow and you risk a buttonhole; too deep and you enter the ciliary body. Once the tunnel is complete and the large capsulorhexis is made, the most critical step is prolapsing the nucleus into the anterior chamber. This maneuver requires patience and gentle hydrodissection to mobilize the lens. Using a vectis to deliver a large, hard nucleus through a manual incision is a tactile experience that teaches you respect for the zonules and the corneal endothelium. Great job by this new surgeon and it shows that if you are a seasoned phaco surgeon, you have no excuse to not learn MSICS! Just do it!
