- 17 Sep, 2024
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Small Incision Cataract Surgery
Small Incision Cataract Surgery
Small Incision Cataract Surgery (SICS) is a technique used for removing cataracts
by making a smaller incision compared to traditional cataract surgery.
Currently, at many teaching institutions, experienced cataract surgeons are attempting
to learn SICS and phacoemulsification concurrently,
Cataract extraction has evolved continuously over the past few decades,
with innovations in surgical technique, wound construction, and intraocular lens (IOL) implantation,
there is a need to train experienced surgeons in SICS and to teach
it from the outset to residents and junior trainees.
Cataract is a clouding of the eye’s lens and is the leading cause of blindness worldwide.
It is usually an age-related process, although certain congenital and hereditary conditions
may result in cataracts in younger patients.
There is no medical treatment to reverse or prevent the development of cataracts.
The most effective way to deal with cataracts and the associated visual loss is surgery
to remove the cataract and implant an artificial intraocular lens.
Small incision cataract surgery is a broad term used to describe cataract surgery techniques
that have relatively recently been developed with the goals of improving safety and reducing
the financial cost to the healthcare provider.
These techniques have a longer learning curve than the older techniques and are far from intuitive
to surgeons who have only been trained in conventional cataract surgery.
It is generally accepted that the safest way to learn these techniques is through structured training programs.
Importance of Training in Small Incision Cataract Surgery
The shortage of both academic and clinical teaching material on small incision cataract surgery
leads to most surgeons attempting to learn SICS by doing so on patients,
a method commonly referred to as “learning on the job”.
The safety of this learning method for the patient can be likened to playing “Russian roulette”
in that the surgeon may get through an operation successfully and without complications
the first few times and become overconfident in his or her skills.
However, it is only a matter of time before an unexpected event occurs during surgery
that cannot be managed by the novice SICS surgeon.
small incision cataract surgery training is a safer alternative to the conventional “learn on the job”
method and provides an environment in which surgeons can feel less intimidated by the jump
in technical complexity from standard cataract surgery to SICS.
Small incision cataract surgery (SICS) has been popularized as a safer and cost-effective alternative
to extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation as a means of cataract surgery.
The slow acceptance of SICS among ophthalmic surgeons can be attributed to the substantial
increase in technical difficulty compared to standard cataract surgery and the perceived increased
risk of complications with the newer technique.
Small Incision Cataract Surgery Training Curriculum
1- Preparing for Small Incision Cataract Surgery:
Having decided to operate, it is always best to try and assess the patient’s systemic
and ocular health and any associated risk factors.
This is because this will affect the anesthesia type selected, the duration of surgery,
and any associated remedial steps.
For example, a poorly controlled diabetic or hypertensive patient may be a risk factor
for intraoperative bleeding.
A patient with high myopia and shallow AC is at high risk for expulsive.
All such cases are better avoided for the beginner.
The crux of the matter is that if one selects easy cases to operate upon, by and large,
the surgeon will do well and be satisfied.
On the other hand, if one selects hard cases, sooner or later complications will occur and the surgeon will end up in trouble!
Here it is important to know when to hand over hard cases to a more experienced surgeon
or alternately operate upon these cases under supervision, i.e. in a setting where immediate
help is available should the need arise.
2- Patient Evaluation and Selection:
A thorough history and examination are performed on all new patients to determine the etiology of visual loss,
determine patient goals, and assess coexisting ocular conditions.
An evaluation of the potential benefits and risks of surgery on a patient-to-patient basis is essential
in determining appropriate candidates for surgical intervention.
Small Incision Cataract Surgery Techniques
1- Incision Creation:
Small incision cataract surgery (SICS) differs significantly from routine extracapsular
cataract surgery (ECCE) as well as from phacoemulsification.
Since SICS is a term that encompasses a variety of techniques, we will discuss the probable
scenario in which a surgeon has learned high-volume ECCE with a superior result in comparison
to a novice phaco surgeon.
In such circumstances, it is most probable that the surgeon will be predominantly interested in techniques
that allow them to efficiently remove the nucleus and cortex.
Thus, could base the discussion in training on nucleus management and the differences
our technique may require in comparison to phacoemulsification.
The marking of the incision location and the construction of the incision itself are very crucial
steps in determining if the surgeon will be successful in performing a cataract surgery without complications.
A surgeon who is new to small incisions will most probably want to start with the superior incision as it is simpler,
but he will encounter a greater amount of problems related to wound construction
and a larger amount of wound leakage than the temporal incision.
With guidance and further practice, surgeons will have success with temporal incisions
at a minimal cost of additional surgery time.
2- Capsulorhexis
Continuous curvilinear capsulorhexis aims to
create an anterior capsule of consistent diameter that will allow the safe and
effective removal of the lens and implantation of an intraocular lens.
3- Phacoemulsification:
phacoemulsification has been shown to result in a quicker and more comfortable visual rehabilitation for the patient.
It also allows the surgeon to make a smaller wound which is self-sealing,
has reduced surgically induced astigmatism, and a lower risk of complications
small incision cataract surgery is useful in cases when phacoemulsification is not suitable
such as white intumescent cataracts and hard brown cataracts.
4- Intraocular Lens Implantation:
Intraocular lens (IOL) implantation is the method by which an artificial lens is inserted into the eye.
It is the only treatment for cataracts and is considered to be one of the most successful
surgical procedures in medicine.
Currently, the most common technique to insert an IOL is to use an IOL injector as this provides
a safer method compared to forceps and also decreases the wound size required for IOL implantation.
Surgical Instruments and Equipment
Surgical advancement has helped a lot to those requiring surgery and has influenced the rapid change
in surgical technique.
Small incision cataract surgery is very demanding on the surgical technique of the surgeon
because it has a steep learning curve.
Small Incision Cataract Surgery Training Wet-Lab
The objective of this Small Incision Cataract Surgery Training Wet-Lab is to allow surgical trainees
to learn the basic techniques of small incision cataract surgery in a controlled environment on simulated models.
This training environment will allow the trainee to learn the basic skills necessary to perform
SICS with the supplementary use of external instrumentation
The wet lab environment should closely simulate a surgical setting where surgeons
will perform small incision cataract surgery.
An artificial eye may be useful for beginning learning, but ultimately,
training on an actual or simulated human cataract provides the most effective means
of developing surgical skills specific to cataract extraction.
Postoperative Care and Follow-up
Postoperative care is very important for good functional results after surgery.
Small incision cataract surgery being a sutureless procedure, the wound must be given time to heal,
hence patients are advised to keep the operated eye clean and dry for a week.
Normally, all patients who have undergone sutureless surgery with foldable IOL implantation attain
good visual recovery within a few hours of surgery.
A follow-up appointment should be scheduled for the next day to assess the patient and the status of the eye.
A basic understanding of the procedure can help patients overcome the fear of the unknown
and can improve their overall surgical experience. Explaining the procedure in layman’s terms
is probably the best way to educate a patient regarding the surgical aspect
Remember, learning Small Incision Cataract Surgery requires dedication, practice, and continuous learning.
It’s essential to seek guidance from experienced professionals and make the most of the available
training opportunities to become proficient in the technique.