MSICS – Global Sight Alliance

White Cataract : To Operate or NOT to Operate, That is the Question?

GSA — Thu, 26 Mar 2020 12:57:58 +0000

I would like to present a patient I saw recently for a second opinion concerning if he was a candidate for a right cataract extraction. This 50-year-old Hispanic male had bilateral poor vision. The patient was initially not forthcoming with his previous medical history other than having a left cataract extraction in the States about 10 years ago. He denied eye trauma or any systemic problems.

The patient had a dense white cataract on the right with superior posterior synechiae between 11:00 to 1:00 PM. On the left the patient had an inferiorly subluxated pc IOL, a macular scar, and old retinal laser marks. There was no view of the right posterior pole due to the mature cataract. The eyes were quiet (no A.C. cells, etc.) with normal IOP’s OU and corneas.

With the mature right dense cataract, I immediately went into my three-step test mode. #1. Color vision was normal. Sees red ( filter ) color as red. #2. No relative afferent pupillary defect (RAPD). #3. But poor light projection even with a dilated pupil. He could not identify / localize / point to where the light was originating.

I advised patient that we could operate on his right cataract but he could have other problems behind the right dense cataract such as a retinal detachment. Then he sheepishly stated that previously in Ca. he was told he had a retinal detachment OD and yes previously he had had laser treatment / surgery OS.

So my point is, as with this patient, this three-step (90 seconds) test will often rule in or rule out eye pathology behind a dense cataract. Leave the B-scan in the States. All white dense cataracts should not immediately have cataract surgery. If the patient can’t see the color red (pink, orange, even yellow is acceptable), don’t operate. If they have a relative afferent pupillary defect (RAPD / Marcus Gunn pupil), don’t operate. If they have poor light projection with a dilated pupil, don’t operate.

You don’t have to make the diagnosis only the prognosis of improving the vision after cataract surgery. Right?

Incidentally, often with a old R.D. the patient has hypotony which was not the case in this patient.

Peace, Baxter

Glaucoma revisited

GSA — Mon, 22 Jul 2019 18:06:45 +0000

I wanted to write again on glaucoma as we all see many patients with glaucoma everywhere — many unfortunately with severe, advanced, end-stage glaucoma when we first see them. As you know, glaucoma is the second leading cause of blindness in the world after unoperated cataracts. Most of what I will say, I’m sure you have heard previously.

Glaucoma can be a difficult disease to diagnosis and treat / maintain. End stage glaucoma is unfortunately often easy to diagnosis as the patient may have marked visual field constriction as well as poor vision OU. You can often rather easily make the diagnosis of end-stage glaucoma as the glaucoma patient can not locate / find ( ambulate ) the eye chair or does not see your extended hand to shake due to the markedly constricted visual fields.

There is no magic number to determine normal patients without glaucoma from patients with glaucoma. You can not say everyone with an IOP over 23 mm has glaucoma and needs treatment for the rest of their life and everyone under 23mm is OK without glaucoma. Life would be easier for the eye health worker if that was true. Please don’t chase / treat the number. Please check IOP a lot ( record ).

However, usually the higher the IOP the more likely that the patient does indeed have glaucoma. Patients can have ocular hypertension with IOP over 22 mm but normal optic disc ( c/d ratio ) and normal visual fields / OCT ( RNFL ). Those patients probably do not have glaucoma and do not need treatment. They certainly need to be followed closely and have frequent IOP checks.

Then there are patients that have normal tension glaucoma with IOP’s never above 21 mm but do indeed have glaucoma and need treatment — abnormal c/d ratio ( enlarged ) and abnormal visual fields / OCT. Glaucoma, early on, is not an easy disease to diagnosis and possibility treat or not treat.

OCT ( RNFL / retinal nerve fiber layer ) is often useful in helping to rule in or rule out early glaucoma. I would not refer glaucoma patients with severe advanced glaucoma for OCT because you already know the nerve fiber layer is thin and you will see a lot of red in the results. No use having the patient and family travel to Belize City for OCT at additional cost for patient and family. No useful information, as you already know the patient has severe glaucoma.

Visual fields ( perimeter ) are quite useful with glaucoma but the patient needs to be taught how to take test. Often the first visual field results are not reliable.

I have left several reference books at all of our clinics: #1. The Physicians Guide to Eye Care #2. Practical Ophthalmology ( blue cover ) #3. Basic Ophthalmology #4. Eye Care in Developing Nations by Dr. Larry Schwab who has spent many years in low-income and middle-income countries. Please read these books and use them as references. Almost every eye problem you will see is described in one or more of these great books.

We can not rule in ( diagnosis ) glaucoma with just the IOP reading. We now have three portable glaucoma measuring devices ( tonometers ) scattered about the country [ I-Care, 2 and TonoPen,1 ]. They can be quite useful in our clinics ( speed up examinations ) and with our outreach activities. Big help. But again you can not use just the IOP to diagnosis as you will be wrong a lot of the time ( ocular hypertension / normal tension glaucoma ). This is why only checking the IOP is not used as a screening technique to diagnosis glaucoma.

Laser trabeculoplasty is not an emergency procedure. Laser trabeculoplasty will not cure glaucoma nor restore vision. However it sometimes reduces the IOP but usually the patient will usually still need to be on treatment ( drops ). You should tell patients that the laser treatment will not improve their vision.

Most of our patients will need to be on more that one glaucoma drop ( agent ) to control their IOP. Timolol is usually effective, cheap, and usually readily available. However often the patient needs more that just timolol to reduce the IOP significantly. That is why some of our glaucoma medicines are actually combinations. You should have your patient bring their drops to their follow up appointments. If you do that, you will be surprised how often your patients are using the drops incorrectly.

Adherence / compliance ( using any medicine as prescribed ) is quite poor with glaucoma. Many of our patients can simply not afford their drops.

Patients with severe optic nerve damage need their IOP as low as possible to prevent further progression ( damage ). Below 15 mm is ideal but often difficult to achieve.

Please give out the glaucoma handouts so our patients can learn more about their disease.

Please ask glaucoma patients to have their family members checked for glaucoma every two years.

Thanks for your efforts.

Peace, Baxter

Phaco -vs- MSICS Complication Rates

GSA — Mon, 22 Jul 2019 14:34:23 +0000

authors
Aravind Haripriya, MD, David F. Chang, MD,
Mascarenhas Reena, MS, Madhu Shekhar, MS

Click here for entire PDF article

PURPOSE: To analyze the rate of intraoperative complications, reoperations, and endophthalmitis with phacoemulsification, manual small-incision cataract surgery (SICS), and large-incision extracapsular cataract extraction (ECCE).

SETTING: Aravind Eye Hospital, Madurai, India.

DESIGN: Retrospective cohort study.

METHODS: This study comprised consecutive cataract surgeries performed during a 12-month period. All surgical complications and endophthalmitis cases were tabulated and analyzed for each of 4 surgeon groups (staff, fellows, residents, visiting trainees). Within each surgeon group, complication rates with phacoemulsification, manual SICS, and ECCE were compared.

RESULTS: The surgical distribution was 20 438 (26%) phacoemulsification, 53 603 (67%) manual SICS, and 5736 (7%) ECCE. The overall intraoperative complication rate was 0.79% for staff, 1.19% for fellows, 2.06% for residents, and 5% for visiting trainees. Extracapsular cataract extraction had the highest overall rate of surgical complications (2.6%). The overall complication rate was 1.01% for manual SICS and 1.11% for phacoemulsification. However, the combined complication rate for trainees was significantly higher with phacoemulsification (4.8%) than with manual SICS (1.46%) (P<.001). The corrected distance visual acuity was better than 6/12 in 96% after phacoemulsification complications and 89% after manual SICS complications (P<.001). There were 27 cases (0.04%) of endophthalmitis but no statistical differences between surgical methods or surgeon groups.

CONCLUSIONS: For staff surgeons experienced with both phacoemulsification and manual SICS, intraoperative complication rates were comparably low. However, for trainee surgeons, the complication rate was significantly higher with phacoemulsification, suggesting that manual SICS may be a safer initial procedure to learn for inexperienced cataract surgeons in the developing world.

Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

MSICS Suggestions – Part 2

GSA — Sat, 06 Jul 2019 19:39:00 +0000

This is the second part ( continuation ) of MSICS suggestions after the SEE course.

After hydrodissection / hydrodelineation and a capsulotomy, if possible spin the nucleus before you rotate it up through pupil into A.C. If unable to spin then just rock nucleus east / west and north/ south. Free it up. You need a large pupil as you must identify the edge ( equator ) of the nucleus so you can lift / rotate nucleus up into A.C. You can use a cannula attached to the viscoelastic or a Kuglen hook or a Sinskey hook or whatever you like to get around ( behind ) equator and lift / dial nucleus.. You can also use viscoelastic to gentle push iris behind equator of the nucleus ( bed-sheeting ) without touching iris with your cannula. This can be especially helpful inferiorly. Go slow.

Before attempting to extract nucleus, check / sweep the wound. Be sure no hang-ups. You need wide open endothelium entrance. Wound construction is such the endothelium opening is 2 mm larger than scleral external opening. In other words you want a funnel or pyramid shaped wound construction. I use a 7 mm scleral opening. With younger patients or with dense, white, mature cataracts the incision sometimes can be smaller.

Once you get nucleus into A.C. then you are ready to extract nucleus from eye. Most surgeons use an irrigating vectis ( loop ). You must protect the endothelium and therefore I put viscoelastic behind the nucleus ( between nucleus and pupil / iris ), in front of the nucleus ( between nucleus and endothelium ) and also on the iris surface right where the corneal endothelium wound starts. In other words I put viscoelastic at 12 o’clock in A.C. to keep iris back when I am removing nucleus with vectis. You do not want iris prolapse as you remove nucleus. Keep the iris back with the viscoelastic.

As you remove the nucleus from the eye , you want several things happening at the same time: #1. Have the A.C. irrigation ( flow ) on #2. Pressure down gently on posterior lip of scleral (external ) wound with irrigating vectis, #3. Rotate globe downward ( away from you ). This is highly important. Many Indian ophthalmic surgeons put in superior rectus bridle suture mainly so they can strongly rotate globe downward as they extract nucleus. If you are sitting temporally then obviously you need to rotate / push eye nasally. You can use 0.12 forceps to rotate the globe downward. Sometimes you can just tell the patient to look down which often helps. This enables the loop to be in the best position ( angle ) to open the tunnel and helps the nucleus to come out.

In the A.C., the loop is carefully advanced under the upper pole ( equator ) of the nucleus. Be careful not to have loop go under the iris as an iris tear / iridodialysis can occur. Don’t sandwich iris between loop and nucleus. Bad news. Most surgeons advance irrigating vectis to the lower edge ( equator ) of the nucleus. Do not creep up ( scoop ) as you extract the nucleus. Do not rub /scrape the nucleus on the endothelium.

If nucleus gets stuck in corneosclera wound, you can try to rotate out or disassemble / debulk with 30 G needle / cystitome. Sometimes gently pressing on posterior lip of wound can help. You can redeposit in A.C. and try again / start over. Be gentle to the endothelium.

There are alternatives ways to remove the nucleus. Dr. A. Hennig in Nepal popularized using a bent 30 G needle ( fishhook) to extract the nucleus.. Dr. Blumenthal pioneered an anterior chamber maintainer. Dr. Kansas / McIntyre / Alfonso used a spatula, bisector or trisector , and a serrated forceps to remove the divided nuclear fragments ( phaco-fracture ).

Some surgeons prefer a quite soft eye /orbit pre-op and use still use a super-pinkie to have a soft eye /orbit. You can have the patient gently hold rolled up socks in a glove ( or whatever ) on the eye for 10 minutes before surgery.

Many surgeons do a lot of their maneuvers through an eight o’clock paracentesis site ( parallel to the iris ) . The paracentesis should be large enough to accept Simcoe I + A unit. One can actually rotate the following / trailing haptic into the posterior chamber through the paracentesis site. Put the push-pull hook into the crotch of the IOL. I would encourage you again to look at You-Tube video examples of MSICS.

Some surgeons routinely leave an air bubble in A.C. at the end. Some surgeons simply irrigate / flush out the viscoelastic rather than trying to aspirate. When in doubt with your wound construction — suture. If vitreous loss occurred, I start patient on an oral floroquinolone. immediately.

Well that’s my suggestions from the SEE course. I would encourage everyone to take a course, look at the videos, do your homework prior to “ having a go “ with MSICS in a developing world setting. Previously there have been MSICS courses at the Academy.

Peace ~ Baxter

MSICS Suggestions

GSA — Sat, 06 Jul 2019 11:04:14 +0000

The three “ new “ MSICS steps for the accomplished phaco surgeon are (1) wound construction, (2) nucleus prolapse into AC, and (3) finally nuclear delivery out of eye. There are many variations / techniques on how to do any / all of these three steps. C heck out YouTube — videos / talks.

The initial wound construction is often 4 plane rather than just a 3 plane incision.

First incision is about ½ thickness into sclera about 2 – 2.5 mm behind surgical limbus, 7 mm in width. Look for a color change as you near the cilary body ( uvea )
The second plane, with a Crescent blade, is into sclera up to surgical limbus.. (Wiggle, wiggle, wiggle). Keep the Crescent flat and create a plane. Look for the tip of the Crescent just entering the corneal limbus. Then stop! Don’t enter A.C. prematurely.
The third plane is up into corneal stroma. Usually need to get more superficial as the radius of sclera ( flatter ) is different from cornea ( 7.8 mm ). If you just happily follow your sclera wound plane into cornea, you will accidently / prematurely enter AC. Quite common. Must get superificial into corneal stroma plane. Get on up. Extend your corneal incision ( plane ) about 2 – 2.5 mm into the clear cornea.
The last incision (plane ) is to dip ( angle ) the keratome down into AC. Wound construction is quite important otherwise iris prolapse doing the operation and you will need sutures on the end. Iris prolapse is to be avoided. No fun.

Some surgeons just open wound through endothelium but extend / enlarge ( laterally and nasally ) endothelium opening only after finishing capsular opening and hydrodissection. The wound must be shaped like funnel or pyramid with the endothelial incision two or more mm larger than sclera opening. “Make the pockets” ( Blumenthal ). You can use Crescent or keratome to enlarge corneal wound.

You can have none, one, or two paracentesis incisions. Simcoe I + A unit should fit through paracentesis incisions.

As I have mentioned previously this is a viscoelastic – dependent operation. Protect the endothelium. Keep the A.C. well formed. Watch the depth of the A.C. Put viscoelastic behind nucleus and in front of nucleus in A.C. ( sandwich ).

The key to getting the nucleus through a capsular opening ( larger casulorrhexis or can-opener ) and into the A.C. is a large pupil. As we all know, a small pupil is not good and a risk factor for vitreous loss. If necessary do a radial iridotomy superiorly under the upper lid or do several small ( one mm ) sphincotomy ( iris ) cuts. Need large pupil. Whatever works for you. Need to identify / locate the equator ( edge ) of the nucleus. Put viscoelastic behind the nucleus and gently lift nucleus. Then dial / rotate / spin nucleus up, into A.C. Lots of variations on YouTube. With phaco you want to keep the nucleus in the bag obviously but with MSICS you have to prolapse nucleus into A.C. Anything you can do to free up nucleus is good — gently rock nucleus east / west and north/south.

Be careful using adrenalin in the BSS bottle unless you are quite sure the adrenalin is preservative free. Adrenalin on the crash-cart is usually not preservative –free.
Do not use any open bottles of fluids the second day of surgery. Must start over with new ( fresh ) bottles ( BSS, etc. ). Quite important.
Can dilute Trypan Blue 50-50 with sterile BSS and use for second case. Can practice using a Crescent blade with a grape.

I would like to close with a quote from one of my grandfather’s books. Rev. Baxter F. McLendon ( Cyclone Mack ) was a Methodist evangelical minister who held tent revivals all over the South and beyond during his hay-day in the 1910’s and 1920’s. When he died in 1935, The Charlotte Observer had a front page picture of Cyclone Mack preaching and holding a chair over his head. He was larger than life and a dynamic pastor / speaker. He preached ( wrote ) love and forgiveness..

“ There are men who believe in Jesus, but they are blinded by the cataract of ecclesiastical ambition or the scales of prejudice have so marred their vision, or the false teaching of fanatics has so covered their optics that they are unable to discern the buds on the tree.” Cyclone Mack.

Peace ~ Baxter

MSICS: Dealing with the Alphabet Soup of Acronyms

GSA — Fri, 05 Jul 2019 23:41:20 +0000

The Global Sight Alliance is focused on the many millions of people in developing countries who lack access to eye care. Most prominent is the effort to provide cataract surgery, as cataract is the leading cause of blindness in virtually all these countries. For delivery of high volume, high-quality cataract surgery in these settings the current state of the art is a technique which has many variations but includes a self-sealing scleral tunnel incision, manual removal of the nucleus, and insertion of a PMMA IOL. The most commonly used name for this procedure, especially in Asia, is Small Incision Cataract Surgery (SICS) or Manual Small Incision Cataract Surgery (MSICS). The name for this technique was generated in India in the late 1990s, and it was appropriate in that time and place because the main cataract surgery techniques in India before that time were standard ECCE and, to a lesser extent, ICCE, both of which entailed incisions larger than 10mm.

Since that time, phaco has become more widely adopted, including in the affluent sectors of developing countries. In its turn, ‘SICS’ has become the procedure of choice in high volume cataract surgery programs in Asia. Depending on the size of the nucleus and the method of extraction, the incision can be as small as 6mm and as large as 9mm. In these days of Micro-Incision Cataract Surgery (MICS), by no stretch of the imagination can this be called a Small Incision. With frequent references in the literature to SICS as meaning standard phaco^1,2, it becomes ever more inappropriate to apply the acronym to this manual technique.

A more logical and unambiguous name is required. The characteristic that makes the technique faster, safer, more economical and more efficacious is that the incision is sutureless. Incision size is irrelevant since improved unaided visual acuity through reduced astigmatism is achieved via appropriate incision shape and placement, not by reducing incision size. Phaco is a form of extracapsular surgery, so ECCE is not appropriate as part of the name. The logical name is Manual Sutureless Cataract Surgery (MSCS). Use of this label will foster clarity and ease communication among surgeons whether in developing or developed countries.

Any comments are welcome on how you have referred to this procedure and if these thoughts seem to reflect the direction then nomenclature should go.

Hayashi K. Post-operative corneal shape changes: Microincision versus small-incision coaxial cataract surgery. J Cataract Refract Surg 2009; 35:233-239 [SICS used to describe phaco through a 3-4mm incision]
Tong N. Changes in corneal wavefront aberrations in microincision and small-incision cataract surgery. J Cataract Refract Surg2008; 34:2085-2090 [SICS used to describe phaco through a 3mm incision]