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