Presented by :Dr. Khan Md. Dedarul Hassan

MBBS: DO (on course)Lions Eye Institute & Hospital

Dhaka, Bangladesh

Small incision cataract surgery

“The right to sight” is the common global agenda launched by WHO and a taskforce of international NGOs to combat gigantic problem of blindness and the aim of vision 2020 is to reduce the current 75 million blind people to 25 million by the year 2020.Cataract is the major cause of blindness with an estimated 16-20 million people being bilaterally blind due to the disease condition.Against this colossal figure for cataract blindness the global annual figure of total cataract surgery is about 7-8 million.

The Right to Sight

Classification of cataract: Congenital or Developmental cataract Acquired Cataract:

Senile cataract Traumatic cataract Complicated cataract Secondary cataract Toxic cataract Syndromes associated with cataract (Down’s

syndrome, Treacher-Collin’s syndrome, Wilson’s disease)

After Cataract

What is “Cataract”?Literally, cataract means “Water fall.”

Any opacity of the lens or its capsule causing visual impairment is called cataract.

History of Cataract surgery:Historians suggest that Egyptians, Greek and Romans performed operations. Sushruta is considered to be the father of cataract surgery, who used to push the lens towards the retina by a needle. The technique called “Couching” was mastered by Indian.With certainly only this can be said that Arabians performed cataract surgery by reclination or depression.Daviel extracted the lens in 1745. it was only after 1870 when antisepsis was discovered that cataract surgery became popular.Casaaonata the count eye doctor of Dresden in 1795 used to perform cataract operation and also implanted artificial lens.But, so far, the history of modern lens implantation goes Harold Ridley of London considered as father of intraocular lens implantation.

Extra capsular cataract extraction:• Conventional method• Small incision cataract surgery (SICS)• Phacoemulsification method

Intra capsular cataract extraction:• Forceps method• Erysophake• Cryo method

Types of cataract surgery:

• Shorter surgical time.• Small incision.• Less scleral scarring.• Less conjunctival scarring.• No or minimal need of sutures.• Deeper posterior chamber allows shorter, more complete

cortical clear out.• Faster healing of scleral incision.• Overall recovery of patient is faster.• Eye is physically stronger in the post operative period.• Less astigmatism induced.• Less chance of posterior capsule tear with deeper chamber.• Less cystoid macular edema.• Can be performed under topical anesthesia.• Shorter retinal exposure to microscope light.• Fewer post operative steroid required.

Advantages of SICS as compared to conventional ECCE:

• It is cost effective.• No expensive infrastructure is required.• No special instruments are required.• Less surgical expertise.• No chance nuclear drop in vitreous.• Decreased endothelial loss in supra hard cataract.• Feasible for all type of nuclei.• Decreased overall risk of complication.• Faster surgical time.• No chance of wound burn.• Short learning curve.

Advantages of SICS as compared to Phacoemulsification:

Visual improvement. Medical indication:

Lens induced glaucoma. Phaco anaphylactic endophthalmitis. Retinal disease like diabetic retinopathy or

retinal detachment. Cosmetic indication ( To obtain black pupil)

Indication of SICS:

1) General medical examination of patient.2) Ocular examination:

Retinal function test. Search for local source of infection. Anterior segment evaluation. SPT Intraocular pressure measurement. B scan ultrasonography

3) Laboratory investigation: Complete blood count. Blood sugar. Urine analysis. Conjunctival swab for C/S.

4) Others :ECG & X-ray chest.

Preoperative evaluation:

1. Topical antibiotics.2. Preparation of eye to be operated.3. Written consent.4. Scrub bath and care of hair.5. Drugs to lower IOP (acetazolamide).6. Drugs to sustain dilated pupil.

Preoperative preparation:

Anesthesia:3 types of anesthesia is used:

1) Topical anesthesia (drops & gel )2) Local anesthesia3) In some cases general anesthesia

Instrumentation for SICS:Basic instruments: Eye speculum Plain forceps Capsulorhexis forceps Lens holding forceps Needle holder Snare Nucleus vectis Nucleus bisector Nucleus trisector Osher hook Sinskey hook Irrigation aspiration canula “J” shaped canula Hydrodissection canula

Special instruments: MVR blade AC maintainer Crescent knife Kerotome Fish hook

Several options are available for making scleral incision:1. Curved Frown shaped with sutures (6.0-

7.0mm)2. Curved Frown shaped without sutures(5.o-

6.0mm)3. Curved Concentric to limbus4. Straight Superior/ Temporal incision (6.0-

7.0mm)5. Straight sutures (oblique, 6.0-8.5mm)6. Triangular Chervon incision (suture less)7. Triangular Straight with backward

extensions

Incisions for SICS:

The size of the wound varies depending on the hardness and size of the nucleus, the technique for nucleus manipulation, the size of IOL used and surgeon’s expertise. The routine SICS incision is 5-6mm but one can make a 3.5-4mm incision.

Dimensions of the incision:

A self-sealing partial thickness scleral tunnel is dissected & anterior chamber is entered.

Capsulorhexis is performed. Hydrodissection is performed and the nucleus is partly

prolapsed into the anterior chamber. A small hook is inserted between the posterior capsule

and nucleus, and the nucleus extracted.It is also possible to extract the nucleus with an irrigating vectis.

The epinucleus and residual cortex are aspirated with a simcoe cannula.

The IOL is inserted. Reposition and anchoring of the conjuctival flap.

Technique of SICS:

Site of implantation: Posterior chamber IOL Anterior chamber IOL Scleral fixated IOL Iris fixated IOL Angle fixated IOL

Flexibility of lens: Rigid or hard IOL (PMMA) Foldable or soft IOL –• Hydrophilic • Hydrophobic• Silicone• Hydrogel

Classification of IOL :

Immediate:o The patient is asked to lie quietly upon the back for about 3

hours an advised not to take food.o Instruct patient avoid coughing, sneezing & avoid bending

from the waist.o Give analgesics.o Provide quite and safe environment.o Notify physician if sudden pain occurs.o Treat nausea or vomiting immediately if present.

Subsequent:o Remove bandage next morning.o Inspect eye for any post operative complication.o Instruct patient and family to instill antibiotic and steroid eye

drops prescribed for 2-4 weeks.o Antibiotic ointment at bed time for a week.o Provide eye-shield.

Post operative care:

1. Care of incision2. Signs of complications.3. Drugs for pain management.4. How to self administer prescribed

medications.5. Amount of weight that can be lifted.6. Diet.7. Follow up.

Discharge instructions:

BUT…..

• Pre-operative complications:During peribulbar block-1)Globe rapture.2)Retro-bulbar haemorrhage.3)Cardiogenic shock.

Per-operative complications:1)During making tunnel-roof fracture & iris prolapse.2)Shallow AC.3)Capsular rapture with vitreous loss.4)Iridodyalysis.5)Posterior dislocation of lens.6)Expulsive haemorrhage.7)Suprachoroidal haemorrhage.

Complications:

Post-operative complications:A.Early (within weeks)-1. Wound leak shallow AC.2. Iris prolapse.3. Pupillary block by-i. Posterior synechiaii. Exudative membraneiii. Optic trap.4 . Corneal oedema.5. Striate keratitis.6. Endophthlmitis.

B.Late (after weeks)-1. Endophthlmitis.2. Posterior capsular opacification.3. Increase IOP.4. Malposition of IOP.5. RD.6. CME.