ArticlePDF AvailableLiterature Review

Small incision cataract surgery: Complications and mini-review

  • Dr. D.Y. Patil Medical College, Dr. Gogate's Eye Clinic, Pune, India

Abstract and Figures

This article reviews the literature on manual small incision cataract surgery (MSICS) and its complications. Various articles on MSICS published in indexed journals were reviewed, as well as the sections on complications of MSICS. The Pubmed search engine on the Internet was used to find out articles published since 1985 on MSICS in any language in indexed journals. Books published by Indian authors and the website of Indian Journal of Ophthalmology were also referred to. MSICS has become very popular technique of cataract surgery in India, and it is often used as an alternative to phacoemulsification. Studies on its efficacy and safety for cataract surgery show that, being a variant of extracapsular cataract surgery, MSICS also has similar intraoperative and postoperative complications. The considerable handling inside the anterior chamber during nucleus delivery increase the chances of iris injury, striate keratitis, and posterior capsular rupture. The surgeon has to be extra careful in the construction of the scleral tunnel and to achieve a good capsulorrhexis. Postoperative inflammation and corneal edema are rare if surgeons have the expertise and patience. The final astigmatism is less than that in the extracapsular cataract surgery and almost comparable to that in phacoemulsification. There is, however, a concern of posterior capsular opacification in the long term, which needs to be addressed. Although MSICS demands skill and patience from the cataract surgeon, it is a safe, effective, and economical alternative to competing techniques and can be the answer to tackle the large backlog of blindness due to cataract.
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January - February 2009 ?????, et al.: ??????? 45
Manual small incision cataract surgery (MSICS) has become
popular in India in the last decade. Cataract is the leading cause
of avoidable blindness in India,[1] and cataract surgery forms
the major workload of most ophthalmic units in the country.
An estimated 4 million people become blind because of cataract
every year,[2] which is added to a backlog of 10 million operable
cataracts in India, whereas only 5 million cataract surgeries
are performed annually in the country.[3] Thus, a technique
of cataract surgery that is not only safe and e ective but also
economical and easy for the majority of ophthalmologists to
master is the need of the hour.
Conventional extracapsular cataract surgery (ECCE),
MSICS, and phacoemulsiÞ cation (phaco) are the three most
popular forms of cataract surgery in India and rest of the
world.[4] Phaco is the technique of choice in the Western world
and tertiary eye care centers in India.
A literature search was performed using the Pubmed
( for articles on small incision cataract
surgery published from 1985 onwards. The search was done
for articles in all languages, although most results were in
English only. Additionally, books on MSICS by Indian authors,
the Indian Journal of Ophthalmology website, the British Journal of
Ophthalmology website, and the Journal of Cataract and Refractive
Surgery websites were also used.
A randomized controlled trial in the United Kingdom
had found phaco to be more e ective than ECCE for the
rehabilitation of cataract patients.[5] Two randomized,
controlled trials in Pune, India, had found MSICS to be more
e ective[6] and economical7 than ECCE and almost as e ective
as[8] and more economical than phacoemulsiÞ cation.[9] MSICS
is also cost e ective and prevents the expenses for the purchase
and maintenance of the phaco machine.[9] MSICS has similar
advantages of phaco in the rehabilitation of the cataract blind.
It is also easier for a surgeon trained in ECCE surgery to master
MSICS than phacoemulsiÞ cation. There is no dependence on
the phaco machine, and the learning curve is less steep than
that of phaco. Surgeons who have mastered MSICS also show a
be" er learning curve for phaco, as the tunnel construction and
capsulorrhexis are common to both. Thus, among small incision
surgeries, MSICS is ideal for developing countries. It was
propagated for high-quality, high-volume cataract surgery at
the Aravind Eye Hospital, India,[10,11] and in Nepal.[12] An expert
trial in Nepal comparing phaco with MSICS published this year,
each done by a surgeon most proÞ cient in that technique, gave
similar results.[13] The MSICS patients had less corneal edema
on the Þ rst postoperative day and similar uncorrected visual
acuity. The surgical time for MSICS was also much shorter.
Some experts were skeptical about the Pune trials,[6,8] as the
same surgeons were randomized to both the techniques, and
doubts were raised that they may not be equally proÞ cient in
the di erent techniques.[14] The Nepal study had the results of
Departments of Pediatric Ophthalmology, Community Eye Care,
H.V. Desai Eye Hospital, Mohommadwadi, Hadapsar, Pune-411 028,
Correspondence to Departments of Pediatric Ophthalmology,
Community Eye Care, H.V. Desai Eye Hospital, Mohommadwadi,
Hadapsar, Pune-411 028, India. E-mail:
Manuscript received: 21.02.07; Revision accepted: 16.08.07
Small incision cataract surgery: Complications and mini-review
Parikshit M Gogate
This article reviews the literature on manual small incision cataract surgery (MSICS) and its complications.
Various articles on MSICS published in indexed journals were reviewed, as well as the sections on
complications of MSICS. The Pubmed search engine on the Internet was used to Þ nd out articles published
since 1985 on MSICS in any language in indexed journals. Books published by Indian authors and the website
of Indian Journal of Ophthalmology were also referred to. MSICS has become very popular technique of
cataract surgery in India, and it is o# en used as an alternative to phacoemulsiÞ cation. Studies on its e cacy
and safety for cataract surgery show that, being a variant of extracapsular cataract surgery, MSICS also
has similar intraoperative and postoperative complications. The considerable handling inside the anterior
chamber during nucleus delivery increase the chances of iris injury, striate keratitis, and posterior capsular
rupture. The surgeon has to be extra careful in the construction of the scleral tunnel and to achieve a good
capsulorrhexis. Postoperative inß ammation and corneal edema are rare if surgeons have the expertise and
patience. The Þ nal astigmatism is less than that in the extracapsular cataract surgery and almost comparable
to that in phacoemulsiÞ cation. There is, however, a concern of posterior capsular opaciÞ cation in the long
term, which needs to be addressed. Although MSICS demands skill and patience from the cataract surgeon,
it is a safe, e ective, and economical alternative to competing techniques and can be the answer to tackle the
large backlog of blindness due to cataract.
Key words: Cataract surgery, intraoperative and postoperative complications, manual small incision cataract
surgery, phacoemulsiÞ cation
Indian J Ophthalmol: 2009;57:45-9
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46 IndianJournalofOphthalmology Vol. 57 No. 1
an accomplished phaco surgeon in the United States compared
with an expert manual small incision surgeon in Nepal.[13]
The MSICS techniques have the nucleus prolapsed into
the anterior chamber as a common step. The nucleus may
be rotated,[15] tumbled (ß ipped so that the posterior surface
faces the cornea and the anterior one is towards the iris) into
the anterior chamber, or may be simple picked up by a bent
cystitome, usually a 26-gauge needle. The nucleus may then
be removed by any of the following techniques:
a. Nucleus delivery using an irrigating vectis,[6,8,10,11] or a
curved cystitome—the Þ sh hook[12]
b. Using two instruments to sandwich the nucleus between
c. Bisecting the nucleus into two using two instrument,
one as the “cu" er” and another, usually a vectis, as the
d. By using a snare similar to the tonsillar snare[4]
e. Dividing the nucleus into three parts (trisection) using a
triangular instrument and a vectis[20]
f. Using an anterior chamber maintainer and a Sheet’s glide
(the Blumenthal technique).[4,21]
g. Viscoexpression of nucleus.
Intraoperative complications
Because MSICS is also a type of ECCE surgery, the complications
are similar, although there are certain unique ones. MSICS
involves more maneuvers in the anterior chamber, Þ rst the
capsulotomy, then dislodging the nucleus from the posterior
to the anterior chamber, and Þ nally removing the nucleus from
the scleral tunnel. The surgeon has to enter again for cortical
aspiration and intraocular lens implantation. The maneuvers
have to be done manually, unlike phacoemulsiÞ cation where
it is done with the machine equipped with ultrasonic power
and vacuum. As such the techniques are more demanding in
terms of manual dexterity and skill. However, the maneuvering
is similar to ECCE rather than phaco, and thus, MSICS is easier
for an ECCE-trained surgeon to master. Excessive corneal
handling, iris injury, posterior capsular rent, and zonulodialysis
are also seen with MSICS. The principles of a good ECCE
surgery, such as not to handle the cornea, to touch the iris
rarely, and to preserve the posterior capsule, all hold good for
MSICS (and phaco), as they are all variants of the conventional
ECCE technique.
Improper construction of the scleral tunnel can lead to
either bu" on holing [Fig. 1], if the tunnel is too shallow, and
premature entry, if the tunnel is too deep [Fig. 1]. There was a
single incidence of scleral tunnel bu" on holing amongst 168
cases in an MSICS series from Pune.[22] This happens if the
crescent knife is blunt or the surgeon has entered a superÞ cial
plane. A poorly constructed tunnel with premature entry causes
trauma to the iris base and may result in iridodialysis and
subsequent hemorrhage in the anterior chamber. The dialysis
can be further extended during nucleus delivery. The premature
entry into the anterior chamber makes the tunnel less self-
sealing, and a box or cross suture may be required at the end.
The continual iris prolapse during the surgery may predispose
to superior iris injury and cha ng, and even iridodialysis in
extreme cases. There would be a greater di culty in nucleus
delivery. To prevent premature entry, the crescent blade should
extend the tunnel into the cornea beyond the blue line, and the
2.8- or 3.2-mm entry keratome should make the inner lip of
the incision at the extreme anterior portion of the tunnel. As
the MSICS tunnels are horizontally longer than those needed
for phaco, the vertical width should be more than 2.5 mm. An
unfortunate superior iridodialysis can be managed by suturing
it into the posterior lip of the incision at the end of surgery.
Rotation or tumbling of the nucleus can put stress on
zonules during its delivery into the anterior chamber especially
through a small capsulotomy.[4] It is also di cult to maneuver
the nucleus through a small pupil and can result in sphincter
damage. The surgeon must take extra care to fully dilate the
pupil before surgery. The anterior chamber should be prevented
from becoming shallow, as that would decrease the dilatation
of the pupil.[4,21]
If the capsulotomy is small (6 mm or less), at least two
relaxing incisions should be placed on the superotemporal and
superonasal part of the continuous curvilinear capsulorrhexis
(CCC) to facilitate nucleus delivery into the anterior chamber
and for the subsequent 12 o’clock cortex aspiration. A can-
opener capsulotomy can also be used but may have been
responsible for an increased incidence of posterior capsular
rents in the Pune study (12/200, 6% in MSICS group vs 7/200,
3.5% in the phaco group).[8] Another series of MSICS had 2/168
posterior capsular rents,[22] while another series of a 100 cases
on white cataracts from South India did not have a single
As prolapsing the nucleus into the anterior chamber is the
key step in almost all the MSICS techniques, pupillary dilation
during surgery is a key facilitator. Small pupils make the nucleus
delivery di cult and increase the chances of manipulation of
the iris and resultant iritis. Inability to prolapse the nucleus
may lead to frustration, increased handling, sphincter tears, and
even abandoning the technique. MSICS should be tried with
caution in cases of iritis, rigid pupil, and pseudoexfoliation.
Beginners are advised to exclude these cases for MSICS, and
ECCE may be a safer alternative. Liberal use of viscoelastic
and patience is recommended even for experts. Tumbling the
nucleus into the anterior chamber is easier through a small
pupil than rotation, but it puts more stress on the capsular
rim and the zonules. Therefore, tumbling the nucleus should
be avoided in incomplete capsulorrhexis, weak zonules, and
Figure 1: (A) Buttonholing of the tunnel (B) Premature entry
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January - February 2009 Gogate: Complications of MSICS 47
Figure 3: Nucleus touching the endothelium
Figure 5: Trapezoid tunnel for better nucleus delivery
Figure 2: Inferior iridodialysis during nucleus extraction
Figure 4: Nucleus surrounded by viscoelastic all around in the anterior
pseudoexfoliation. In conditions of weak zonules like minimal
subluxation, pseudoexfoliation, and hypermature cataracts, it is
be" er to gently li# the nucleus into the anterior chamber with a
bent cystitome rather then tumble or rotate it.[12,15] Hypermature
and black cataracts have capsules that are already stretched
out and thin, with stress on the zonules. ECCE may be a safer
alternative,[4,24] although a study on phacolytic glaucoma has
shown MSICS to be safe and e ective.[25] Pseudoexfoliation
with its rigid small pupil and weak zonules o ers a special
situation. Trypan blue dye may be used to get a complete large
capsulorrhexis and the nucleus gently rotated or li# ed into the
anterior chamber.[23,25]
Another very rare complication that is unique to
viscoexpulsion or phacosandwich technique of MSICS is
inferior iridodialysis.[10,16,23] In the irrigating vectis technique, if
the irrigating vectis is inadvertently placed below the pupillary
margin rather than between the margin and the nucleus, the
inferior part of the pupillary sphincter gets caught between the
vectis and the nucleus during nucleus delivery. This causes a
tear at the 6 o’clock iris base [Fig. 2], which was seen in a single
case (1%) in a series from South India.[23] The resultant bleeding
and the di culty in suturing the large inferior iridodialysis
can be frustrating.
A posterior capsular rent in MSICS does not cause a lot of
vitreous loss like the ECCE, as the chamber is closed. However,
aspiration of the epinucleus or sheets of cortex becomes
di cult. In the event of capsular rent, dry aspiration can be
done by a Simcoe canula if the rent is small, or by an automated
vitrectomy cu" er if it is larger.[4,24] If the rent is small, the
posterior chambers intraocular lens (PCIOL) can be implanted
in the bag or on the anterior capsular ß ap for a large rent. If the
PCIOL is not stable or the rent is too large, the only option is
to perform a good vitrectomy and put in an anterior chamber
intraocular lens implant (ACIOL). A peripheral bu" on hole
iridectomy must be done in all cases of the posterior capsular
rupture. If there is a slightest doubt about the integrity of the
tunnel, it is always wiser to suture. In case of doubt, it is be" er
to suture and be safe, than hope to be lucky.
Striate keratitis is common during MSICS if enough care
is not taken to place the viscoelastic between the nucleus and
the cornea [Figs. 3 and 4]. The side-port is an excellent route to
ensure this. Delivery is facilitated through a trapezoidal tunnel
[Fig. 5]. Delivery of the nucleus through a small tunnel or
rectangular tunnel can cause damage to the corneal endothelium
[Fig. 6] and long-standing corneal edema, which is recalcitrant
to treatment. The phacofracture,[18,19] phacosandwich,[16,17] and
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48 IndianJournalofOphthalmology Vol. 57 No. 1
trisection[20] techniques popularized in the 1990s did not gain
wide acceptance, as they involved considerable manipulation
into the anterior chamber with two instruments in addition
to the nucleus. This made the technique very demanding on
expertise and patience, and chances of corneal edema a# er
surgery were very high in the learning phase. It was all the
more di cult for very hard and white cataracts, which form
the bulk of work in India.[4,24] The two techniques were easier
for so# er cataracts, but paradoxically the so# er cataract nucleus
could be delivered out without such intense manipulations by
viscoexpression alone.
Postoperative complications
If proper wound integrity was not maintained, shallowing of
the anterior chamber will be seen during the Þ rst dressing.
A cross suture or box suture during learning phase and for
larger tunnels for hard nuclei would be helpful. Wound gape
and iris prolapse in the scleral tunnel increase the chance of
endophthalmitis and astigmatism. Postoperative corneal edema
and potential corneal decompensation are common in poorly
performed MSICS. The trial in Pune had nine (4.5%) cases
of postoperative corneal edema on the Þ rst day in the phaco
arm and four (2%) cases in the MSICS arm.[8] A series of white
cataracts had 65 eyes with corneal edema of >10 descemets folds
and 7% with corneal edema of <10 descemets folds.[23] In the
Nepal study, both groups had an average increase in the central
corneal thickness on the Þ rst day, but the MSICS group had less
corneal edema (P = 0.0039).[13] The edema had decreased to 29
and 4 mm in the phaco and MSICS group, respectively, on the
Þ # h day, and by the third month, it had returned to baseline in
both groups. Most studies of MSICS report a transient corneal
edema, which clears o by the Þ rst week,[8,17,19,20,24,26] but a series
from Ghana had a single case (0.5%) of bullous keratopathy.[26]
A clinical audit of more than 8000 cataract surgeries done in
Pune had found 12 cases of corneal decompensation, all of
which were due to MSICS.[27] However they were performed
by surgeons in the learning phase of MSICS. MSICS should be
done with caution in very old patients, those with very hard
cataracts, and those with not so clear corneas.[4,24,27]
The MSICS involves touching the iris at some point of
time. This may lead to higher incidence of postoperative iritis
and cystoid macular edema.[13,23] Nevertheless, the studies
so far have not shown any di erence or increase in these
complications.[8,9,25] The series from south India had mild
iritis in 6% and moderate iritis in 3% in the Þ rst postoperative
week.[23] The large self-sealing tunnel may increase the chances
of endophthalmitis, although further studies would be needed
to support or refute the hypothesis. A study from Trichy,
India, had demonstrated no significant anterior chamber
contamination in MSICS.[28]
A large systematic review of posterior capsular opaciÞ cation
(PCO) rates in 1998 had put it at 11.8% at one year and 28.4% at
Þ ve years.[29] Advances in surgical techniques and improvement
in intraocular lens material and design have reduced the rates
of PCO or, at least, have prolonged its onset.[30] The slight
superiority of phacoemulsiÞ cation may be due to the lower
incidence of PCO. In the Nepal study, 20/46 (43.5%) patients
of MSICS had grade 1 PCO, and 8/46 (17.4%) had grade 2 PCO
at the 6-month follow-up. For the phaco group, 7/48 (14.6%)
had grade 1, and none had grade 2 PCO at the 6-month follow-
up.[13] The automated irrigation aspiration and the capsular
polish mode in phaco may give it a small edge over MSICS.
Also, the foldable lenses used in phaco had a square edge as
compared with the polymethyl methacrylate (PMMA) lenses
used in MSICS. A good cortex aspiration and polishing the
capsule are necessary a# er MSICS. If a can-opener or V-shaped
capsulorrhexis is used in MSICS rather than the CCC, there may
be increased chances of PCIOL decentration later.
The average astigmatism was 0.7 diopter (D) in the phaco
and 0.88 D in the MSICS (P = 0.12) in the Nepal study.[13] The
Pune study had the mode of astigmatism of 0.5 D for phaco
and 1.5 D for MSICS, though the average was 1.1 and 1.2 D,
respectively.[8] Both the studies had used a foldable lens in the
phaco arm, though diamond knife and silicone lenses were
used in the Nepal study and stainless steel keratome blades and
hydrophilic acrylic lenses in the Pune study. A prospective trial
comparing 3.2-mm incisions with 5.5-mm incisions in Japan
had found the di erence in astigmatism of 0.3D.[31] A study
from Mumbai, India had found temporal and superotemporal
tunnels to induce less astigmatism as compared with superior
tunnels for MSICS.[32] The mean astigmatism was 1.28 D at
2.9 degrees for superior incisions, 0.20 D at 23 degrees for
superotemporal incisions, and 0.37 D at 90 degrees for temporal
ones. The authors believed that temporal incisions were the
farthest from the visual axis, and gravity and eyelid blink would
create a drag on the superior incisions. They recommended
duplicating the study with a larger sample size.
A study comparing endothelial cell loss and surgically
induced astigmatism among ECCE, MSICS, and phaco had
found the induced astigmatism slightly more in MSICS than
phaco but much less than ECCE.[33] There was no signiÞ cant
difference in the endothelial cell loss among the three
MSICS is a safe surgery.[6,8,11-13,23,24] The surgeon has to be extra
diligent in tunnel construction as the tunnel size is larger. An
excellent self-sealing incision is vital for wound architecture
on which the safety and lowered astigmatism potential rests.
The incidence of posterior capsular rent and iridodialysis is
low, and in case of such an eventuality, it is easier to manage
the vitreous loss. In MSICS, the prolapse of nucleus into the
anterior chamber and its delivery through the tunnel involve
Figure 6: Nucleus gets caught in a rectangle tunnel
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January - February 2009 Gogate: Complications of MSICS 49
manipulations very close to the iris and the cornea. The surgeon
has to be extra careful with these structures, as postoperative
inß ammation and corneal edema can be all too common.
More a" ention needs to be paid to cortical wash and capsular
polishing, as PCO may be the only factor for suboptimal visual
acuity in the future.
I am thankful to the editorial board of the Indian Journal of
Ophthalmology for giving me the opportunity to write this
article. Prof. Col. Madan Deshpande helped with his valuable
inputs, and Dr. Roma Deshpande, Dr. Anita Bhargava and
Dr. Prachi Amberdekar with the illustrations.
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Source of Support: Nil, Con ict of Interest: None declared.
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... The phacoemulsification technique, as was already mentioned, is an important point in the development of corneal edema. According to some authors, microincision cataract surgery (MICS) results in a smaller corneal incision, which has been shown to reduce wound misalignment and to carefully preserve the corneal integrity after the cataract removal procedure [13,46,53,55,56,99,100]. They reported fewer changes in corneal endothelial cell loss, pachymetric parameters, and corneal edema over the short term, as well as fewer induced corneal aberrations in the long term [13,55,56,82]. ...
... Some of these techniques have demonstrated various benefits in terms of ultrasound power (USP) and effective phacoemulsification time (EPT) in order to cause less endothelial cell loss. As a result, these methods have been modified for the treatment of dense cataracts, which remain a challenge in the cataract surgery process [24,28,32,35,38,49,54,100]. Zhao et al. investigated this specifically, comparing reverse-chopper nucleus extraction in dense cataracts to conventional stop-and-chop under the same conditions. ...
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Citation: Briceno-Lopez, C.; Burguera-Giménez, N.; García-Domene, M.C.; Díez-Ajenjo, M.A.; Peris-Martínez, C.; Luque, M.J. Corneal Edema after Cataract Surgery. Abstract: This systematic review investigates the prevalence and underlying causes of corneal edema following cataract surgery employing manual phacoemulsification. A comprehensive search encompassing databases such as PubMed, Embase, ProQuest, Cochrane Library, and Scopus was conducted, focusing on variables encompassing cataract surgery and corneal edema. Two independent reviewers systematically extracted pertinent data from 103 articles, consisting of 62 theoretical studies and 41 clinical trials. These studies delved into various aspects related to corneal edema after cataract surgery, including endothelial cell loss, pachymetry measurements, visual performance, surgical techniques, supplies, medications, and assessments of endothelial and epithelial barriers. This review, encompassing an extensive analysis of 3060 records, revealed significant correlations between corneal edema and endothelial cell loss during phacoemulsification surgery. Factors such as patient age, cataract grade, and mechanical stress were identified as contributors to endothelial cell loss. Furthermore , pachymetry and optical coherence tomography emerged as valuable diagnostic tools for assessing corneal edema. In conclusion, this systematic review underscores the link between corneal edema and endothelial cell loss in manual phacoemulsification cataract surgery. It highlights the relevance of factors like patient demographics and diagnostic modalities. However, further research is essential to unravel the complexities of refractive changes and the underlying mechanisms.
... Cataract surgery has evolved dramatically over the last 2 decades; however, surgeons should always be prepared to manage any possible complication. Common corneal complications of cataract surgery include errors in dimension and orientation of corneal incision, corneal edema due to elevated ultrasound use, and tears of Descemet's membrane [1][2][3][4]. Corneal infiltrates (CIs) are not described as a complication of cataract surgery itself [1][2][3][4]. ...
... Common corneal complications of cataract surgery include errors in dimension and orientation of corneal incision, corneal edema due to elevated ultrasound use, and tears of Descemet's membrane [1][2][3][4]. Corneal infiltrates (CIs) are not described as a complication of cataract surgery itself [1][2][3][4]. Generally, when facing CIs, it is necessary to determine whether the etiology is sterile or infectious [5,6]. ...
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We report a case series of 26 eyes of 26 patients undergoing planned cataract surgery from December 2021 to March 2022, who were diagnosed as having whitish round infiltrates in the surgical corneal incisions. The infiltrates were detected at the first check after 5–8 days from cataract surgery and were located either within the main corneal incision and/or in the smaller incisions. Corneal infiltrates (CIs) were single or multiple, without epithelial defects, and painless. All infiltrates were initially treated with full topical antibiotic coverage, in order to control eventual and serious postsurgical infection. However, at daily checks, the clinical course of CIs suggested a sterile etiology. For this reason, steroidal topical treatment was maintained for a long time with slow tapering until complete remission of the CIs. All infiltrates resolved completely in around 30–40 days. The surgical instruments and the sterilization process were scrutinized. A white amorphous material was found mainly on non-disposable anterior chamber cannulas and on irrigation/aspiration tips. Disposable cannulas were adopted, and machinery for cleaning and sterilization procedures were reviewed, with specific reference to water softener renewal. Thanks to these precautions, CIs never occurred again. Finally, our hypothesis was an immune corneal reaction to amorphous deposit on cannula tips. This case series describes a previously unknown complication of cataract surgery and our experience might be useful for other surgeons.
... Although manual small incision cataract surgery has been widely employed as the go-to option for the operative treatment of cataract. 4,5 Extracapsular cataract extraction with posterior chamber intraocular lens implantation (PCIOL) had been the most widely performed cataract corrective surgery before 15 Years and is still employed in some setups. 6 Extra capsular cataract surgery was deemed as one of the most successful and safe procedures for correction of cataract until the wide and prevalent shift to manual small incision cataract surgery. ...
... They reported the prevalence to be around 1%. 13 The finding of our study where residual cortex was seen to be prevalent as a post-operative complication was also higher than the prevalence reported Tiwari et al. 14 Endophthalmitis had the highest prevalence as a postoperative complication of MSICS was justified by Goghate in 2009. 4 However, studies conducted by Ravindran suggested otherwise where endophthalmitis had more chances of occurring in ECCE than in MSICS. 15 In this study it was noticed that posterior capsular opacification was seen only in ECCE and no cases were noticed in MSICS, similar finding was reflected in a review where it was suggested that posterior capsular opacification was more prevalent in ECCE than in MSICS. ...
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Background: Dilemma of cost effectiveness of manual small incision cataract surgeries (MSICS) in the terms of training and equipment has been widely pondered upon in developing areas. Objective of the study is to compare the manual small incision cataract surgery and extra capsular cataract extraction.Methods: A prospective study was conducted among the IPD patients of the Ophthalmology Department of Khaja Bandanawaz Teaching and General Hospital, Kalaburagi, from June to December 2017. Statistical Analysis was performed using Microsoft Excel 2013, SPSS 23.0 and Chi-square test was performed.Results: Out of the 160 individuals who underwent extra capsular cataract extraction (ECCE), 06 (3.75%), 91 (56.88%) and 63 (39.37%) of the study subjects had poor (5/50), moderate (6/60-6/24) and good (6/18-6/6) visual acuity respectively. Highest incidence was that of lens prolapse (25%) and corneal complications (25%) in ECCE. Among the subjects who underwent MSICS, highest incidence of intra operative complication noticed was that of lens prolapse, iris prolapse and anterior chamber collapse, each at 20%.Conclusions: It was concluded that the restoration of visual acuity was fairly good and uniform in both the procedures. Certain intra operative complications such as lens prolapse, iris prolapse and anterior chamber collapse were noticed in MSICS and capsular flaps and vitreous loss were noticed only in ECCE.
... The percentage is higher for the low vision,The reason for the failure of this surgery is that the solution to this problem is greatly reduced with the use of heparin sodium in the washing solution. This study show that the problems and complication becoming after surgery can prevent with heparin use (1,4,8,10) ...
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After cataract extraction of the child's eye, the vision is reversed (decreases), because after surgery Fibrin is found in anterior chamber, for prevention of formation fibrin we use heparin and does not decrease the vision. The aim of this research is to study of use and non-use of heparin in children eye surgery, differentially. This is case control study conducted on sartan 1397 to jawza 1398 within one year on 30 patients in University Teaching Hospital Eye ward. In group A, there were 14 eyes that used heparin sodium in surgery and in group B there were 16 eyes that had surgery with no heparin sodium uses. Statistical analysis of the study revealed that the odds ratio is 7.714 that is seven times greater use of heparin with improvement and better result. the p valve is 0.0256 which is very close to the fact and Z statistic is 2.233. In research group A in which we used heparin in cataract surgery 2 eyes 14, 28% had a posterior capsule density, one patient had a posterior synechia that gave 7, 14%, and two patients who had hyphaemia that gave 14,28%,that mean anterior chamber had blood. In B group three eyes pupil completely close mean had occulosive pupil 18, 75%. In the study 14 female gender 46, 66% and 16 male genders 53, 33 % were in observation. And research has shown that the use of heparin to prevent the complications of cataract surgery in children is most likely having good result.
... MSICS has advantages, but it does not come without risks. As this procedure involves manipulation of the anterior chamber during nucleus delivery, intraoperative complications include iatrogenic iris trauma, striate keratopathy, and posterior capsular rupture, while postoperative complications include inflammation and corneal edema [3]. Here, we present a rare case of posterior chamber intraocular lens (PC-IOL) extrusion through the scleral tunnel created during MSICS after blunt trauma as an unexpected complication of MSICS. ...
Traumatic posterior chamber intraocular lens (PC-IOL) extrusion via a self-sealing scleral tunnel, created for manual small-incision cataract surgery (MSICS), is a rare occurrence that has never been reported before. Usually, the PC-IOL protrudes through a ruptured cornea or falls back into the vitreous after blunt trauma. Here, we present a case of PC-IOL extrusion along the uveal tissue through the scleral tunnel in an 80-year-old woman with a history of MSICS who fell and hit her right eye on the stairs, resulting in sudden and painful loss of vision in the same eye. The IOL, along with necrotic uveal tissue, was removed from the subconjunctival space, and the ruptured scleral tunnel was sutured. After initial management, her best-corrected visual acuity (BCVA) was 6/36 with aphakic spectacle correction. The patient was advised to undergo secondary scleral fixation of the intraocular lens. The scleral tunnel made in MSICS is a potentially weak area, and the PC-IOL can come out through it. Therefore, suturing the scleral tunnel with a non-absorbable nylon 10-0 suture should be considered during MSICS. This provides additional support to the weakened scleral wall.
... A clear corneal incision in cataract extraction surgeries may be accompanied by both early and late corneal complications, including wound leakage, corneal astigmatism, epithelial ingrowth, Descemet membrane detachment, and wound burn [1][2][3][4]. Most surgeons are familiar with these complications and their management. ...
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Background: Description of an abnormal corneal lesion as a complication of a clear corneal incision in cataract surgery. Case presentation: A 55-year-old woman presented, complaining of right eye pain and redness for 6 months, which started 1 month after her uncomplicated cataract surgery. On gross examination, the bulbar conjunctiva was hyperemic and a vascularized salmon-pink nodule with a smooth surface was noted over the supratemporal region of the cornea, just anterior to the previous superior corneal incision, with superficial feeder vessels originating from the adjacent conjunctiva toward the lesion. The lesion was removed and histopathological examination revealed an inflammatory tissue containing inflammatory cells and capillaries within a background of fibrotic tissue throughout the lesion. Conclusions: Reactive fibrovascular nodules are rare corneal lesions following corneal trauma and vascularization, including a clear corneal cataract surgery incision. Ophthalmologists may encounter these lesions during postoperative visits and should be familiar with their appearance and management.
... Wound leak Weak tunnel, subtle premature entry, or buttonhole can sometimes be missed intraoperatively, and if sutures are not placed intraoperatively can result in a postoperative day-one wound leak which should be sutured on the same day. [2] Conjunctival Retraction If the conjunctiva is not cauterized correctly or if there is an irregular breach of the conjunctiva during the peritomy, it can result in conjunctival retraction and exposure of the scleral incision. This requires conjunctival suturing or repeat cautery postoperatively to minimize the risk of endophthalmitis. ...
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Dear Editor, We read the interesting review article by Goel et al.[1] on complications of manual small incision cataract surgery (MSICS), and we must congratulate the authors for this comprehensive review. However, we have we important additions to make, which we believe will be helpful for all the surgeons performing a large volume of MSICS. Having performed a large volume of MSICS and managed quite a few complications at a high‑volume tertiary eye care center, we believe it is extremely important to examine the patient on the first postoperative day and document any subtle early postoperative complications.
... However the safest, most effective and economical technique of cataract surgery remains debatable [2,3] . Over the past decade SICS has become an established surgical alternative to Phacoemulsification. Phacoemulsification is the preferred technique in the developed world and tertiary centres of developing world [4,5,6,7,8,9] . Phacoemulsification requires a much smaller incision (3.2mm) than SICS but the incision size is dependant on the Phaco machine being used. ...
... Handling the instruments that are introduced in the anterior chamber is a continuous learning process, so all surgeons at every level of their career should emphasize on improving one's own technique. [3] The surgical techniques in cataract surgery are evolving toward a safer side in terms of endothelial protection, so one should not hesitate in adapting a new and safer technique. ...
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Small incisidn extracapsular cataract extraction (ECCE) using the sandwich techniqueis described. After capsulorhexis, hydrodissection, and hydrodelineation, the endonucleus is moved into the anterior chamber and extracted by sandwiching it between the irrigating vectis and iris spatula. In a series of 37 eyes, most achieved a best corrected visual acuity of 5/10 or better postoperatively. Complications were posterior capsule rupture, vitreous loss, and transient corneal edema. Small incision ECCE using the sandwich technique is safe, easy, and does not require expensive instrumentation.
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Globally, it is estimated that there are 38 million persons who are blind. Moreover, a further 110 million people have low vision and are at great risk of becoming blind. The main causes of blindness and low vision are cataract, trachoma, glaucoma, onchocerciasis, and xerophthalmia; however, insufficient data on blindness from causes such as diabetic retinopathy and age-related macular degeneration preclude specific estimations of their global prevalence. The age-specific prevalences of the major causes of blindness that are related to age indicate that the trend will be for an increase in such blindness over the decades to come, unless energetic efforts are made to tackle these problems. More data collected through standardized methodologies, using internationally accepted (ICD-10) definitions, are needed. Data on the incidence of blindness due to common causes would be useful for calculating future trends more precisely.
Data from a population based longitudinal study of randomly selected communities in Central India have for the first time provided direct estimates of age specific incidence of blindness from cataract. Person-time denominators have been used to compute age specific incidence rates (risk) of blindness from cataract for populations aged 35 and older. These age specific incidence measures have been applied to the 'population at risk' in each 5-year age class in order to estimate the total number of new cases of cataract blindness that occur in the country each year. The findings indicate that an estimated 3.8 million persons become blind from cataract each year in India (approximate 95% confidence limits: 3 to 4.5 million). The reasons why the estimates are considered as minima, and their implications concerning future national planning of ophthalmic services, are briefly discussed.
The lens glide is a disposable sterile plastic piece designed to achieve smooth, easy, safe expression of the nucleus in planned extracapsular cataract extraction. The advantages of the technique include prevention of iris prolapse or iris trauma, controlled nucleus extraction without sudden nucleus expulsion, direction of the nucleus toward the external opening, and prevention of malengagement of the nucleus to the anterior chamber angle or vitreous cavity. Using the glide facilitates extraction of a nucleus through a small limbal or scleral incision. Combining the glide with other modern surgical techniques, such as scleral tunnel small incision, capsulorhexis, and hydrodissection, results in a no-stitch low astigmatic wound and stable intraocular lens fixation in the capsular bag.
To compare the intraoperative complications of planned extracapsular cataract extraction (ECCE) with those of manual nucleofragmentation. Hospital de la Esperanza, Universitat Autónoma de Barcelona, Spain. This retrospective study comprised 567 eyes; 444 had planned ECCE and 123, manual nucleofragmentation through a scleral tunnel incision. No significant differences between techniques were found in terms of intraoperative complications (P < .05). Manual nucleofragmentation did not increase the risk of intraoperative complications (P < .05). Although phacoemulsification is the procedure of choice in many cases, manual nucleofragmentation is a safe and valid alternative that achieves the goals of small incision cataract surgery.
To compare the long-term clinical results of two small incision cataract surgery procedures. Seven centers in Japan. Two hundred eyes were randomly assigned to receive a silicone intraocular lens (IOL) through a 3.2 mm incision or a poly(methyl methacrylate) (PMMA) IOL through a 5.5 mm incision. Except for incision size and implantation technique, the surgical methods were identical. Uncorrected and corrected visual acuity, keratometry, flare-cell intensity, specular microscopy, and neodymium:YAG (Nd:YAG) laser posterior capsulotomy rate were analyzed up to 3 years after surgery. Eyes in the 3.2 mm incision group had significantly better uncorrected and corrected visual acuity in the early postoperative period and lower aqueous flare intensity immediately after surgery, but these differences disappeared after the first postoperative month. However, surgically induced astigmatism was significantly less in the 3.2 mm incision group than in the 5.5 incision group throughout the study. The Nd:YAG laser capsulotomy rate was higher in the silicone IOL group (23.5% at 3 years postoperatively) than in the PMMA IOL group (18.4%) but the difference was not statistically significant. Smaller incision cataract surgery led to early recovery of visual function in the short term and less induced astigmatism in the long term.
Reported rates of posterior capsule opacification (PCO) vary widely and are based on various definitions of PCO, varying lengths and intervals of follow-up, and the use of different surgical techniques, intraocular lens (i.o.l.) designs, and methods of IOL implantation. This study was designed to obtain a more precise overall estimate of the incidence of PCO and to explore factors that might influence the rate of PCO development. A meta-analysis. Published articles were selected for study based on a computerized MEDLINE search of the literature and a manual search of the bibliographies of relevant articles. Articles meeting selected inclusion criteria were reviewed systematically, and the reported data were abstracted and synthesized using the statistical techniques of meta-analysis. Pooled estimates of the proportion of eyes developing PCO at three postoperative timepoints--1 year, 3 years, and 5 years--were measured. There is significant heterogeneity among published rates of PCO. The overall pooled estimates (95% confidence limits) of the incidence of PCO were 11.8% (9.3%-14.3%) at 1 year, 20.7% (16.6%-24.9%) at 3 years, and 28.4% (18.4%-38.4%) at 5 years after surgery. There is no evidence of a significant decline in PCO incidence during the study period. Visually significant PCO develops in more than 25% of patients undergoing standard extracapsular cataract extraction or phacoemulsification with posterior chamber intraocular lens implantation over the first 5 years after surgery. Patient characteristics, surgical techniques, and differences in research design and reporting may account for some of the variability in reported rates. However, no specific factors were identified in the authors' analysis. More precise estimates of incidence and identification of risk factors for PCO will depend on the development of a standardized measurement of PCO and wider adoption of more rigorous study methodology.