How to Graduate from SICS to Phacoemulsification

 When you think of modern day cataract surgery, Phacoemulsification (PE) immediately comes to your mind. It is time tested, best cataract surgery in the world. So every eye surgeon in India and Abroad wants to learn this technique. Medical education in India is such that not many of the post graduate medical colleges are teaching this technique practically. Most of our postgraduates pass their exam without doing even a single case of Phacoemulsification (PE).  Manual small incision Cataract Surgery (SICS) is the most commonly done eye surgery in India. Most of the eye surgeons and post graduates are able to do it. So everyone who is not doing PE wants to graduate from SICS to PE.

There are a few mental and technical prerequisites before making the transit from SICS to Phacoemulsification.

Mental prerequisites:

·         Remove fear & gain confidence.

·         Back up of experienced surgeon in OR (preferable)

·         Master one technique (copy one surgeon)

·         Case selection

Let’s elaborate on this- When one decides to leap ahead and shift to Phacoemulsification, it is best to introspect first. Am I prepared? One must ensure what exactly he/she is going to do and preferably start in presence/guidance of an experienced surgeon. One should have no confusion regarding the technique he is going to opt, rather try to copy the senior’s technique and then try to innovate later.

 Imagine your plan A for the whole case and introspect after every case for further improvement. Plan B must always be ready to take care of catastrophe. One must be able to identify the complications early and should be prepared to convert the case back to SICS or ECCE with no place for ego in mind.

Before choosing a case for phaco, co-morbidities must be seen before hand. Ensure a clear cornea, well dilated pupil and a NS 3 cataract. Have an eagle’s eye for deep set eyes, zonular dialysis, pseudoexfoliation, high myopia, posterior polar and very soft/hard cataracts.

The surgery should not be kept on a busy day. You should attempt when you are relaxed and not tired at all. Patient should be having good vision in his other eye and should not be very demanding.

It would be a piece of cake if you plan your OT with a senior surgeon, as his/her presence would not only boost up your confidence but also help you out in situation of crisis if any.

Technical prerequisites:

·         Hand, eye and foot co-ordination

·         Amphi-dextricity

·         Being friendly with machine

·         Ability of good wound construction & capsulorrhexis

·         Good microscope and phaco machine

·         Choice of anesthesia it should be Peribulbar or posterior sub tenon’s

SICS/ECCE surgeon must start making side ports, using instruments in the non-dominant hand and doing good capsulorrhexis.

I would suggest beginners not to start on a 2^nd or 3^rd hand machine as this makes our journey further difficult. The machine should be user friendly and the surgeon must understand the parameters for every step he/she is going to do. The simple tip here is again to copy someone whom you have seen operating and have an access to discuss the same.

Always plan before you enter and be ready to introspect, discuss and kill your ego whenever required.

Always use sharp blades, and be liberal with the use of viscoelastics, trypan blue and other consumables if required.

Manual SICS is a simple surgery. First of all two side port incisions are made at three and nine o’clock positions. Chamber is filled with visco-elastic and capsulorhexis is performed from the side port. Though capsulorhexis is preferred, Manual SICS can be performed even without complete rhexis or even after “Can-opener” capsulotomy. Here after undermining the conjunctive heamostesis done. A frown incision is given just behind the limbus. It is astigmatic neutral zone. Using crescent knife a sclera- corneal tunnel is made. Here we make deep pockets on both sides. Cornea is entered by 2.8 mm keratome and tunnel is extended on both sides by enlarging keratome.  Hydro dissection is done to prolapse out the nucleus. Nucleus is rotated to make it free from the bag.

There are various methods to bring the nucleus out of AC. I prefer ‘Sandwich technique’.  In this, after putting viscoselastic (OVD) above and below the nucleus, Wire vectis is kept behind the nucleus and Sinskie hook above it. They are gently pressed together and withdrawn slowly. They come out with nucleus in between them. Visco- expression of cortical matter is done. Rest of cortical matter is removed by Simcoe canulla. OVD is put again to form the chamber. Single Piece PMMA less is inserted in the bag. After hydrating the wound on both sides, OVD is removed by Simcoe canulla and chamber is formed. We press on top the cornea to check the integrity of wound. It is padded for at least 3-4 hours.

On the other hand, Phacoemulsification is a totally equipment based surgery. In Phacoemulsification after making side port incision, chamber is filled with OVD. In superiotemporal part of the limbus, a scratch incision is made at the 9 o’clock position.  From this incision, we make about 2mm of corneal tunnel by 2.8 mm keratome. Rhexis is performed from side port. Some people prefer to do rhexis from main corneal tunnel using Utrata’s forceps. Hydro dissection is performed to separate the nucleus from the capsule. Here we perform cortical cleavage hydro dissection. We press the centre of nucleus after each hydro dissection. We see the fluid wave travelling behind the nucleus. After this, a central trench is made in the nucleus. Nucleus is divided into two halves. Finally, they are emulsified one by one.

If you are not already doing capsulorhxis in all your cases of SICS, start doing it in all cases. Here is how you should start. After making side port incision trypan  blue dye is put in to the AC under Air (that is first air and then dye is put in the AC) after 5 seconds dye and air is replaced by OVD put into the eye from the side port. A cystitome is made from 26G- 27G needle. Cystitome is taken into eye from side port and 2.5mm incision is made on the anterior capsule of the lens starting from centre towards periphery. Then this is lifted up to make a flap which is engaged by the tip of cystitome and rotated circumferentially to complete the capsulorhexis. Ideally capsulorhexis should have 5.5mm diameter.

Before entering with phaco probe into the eye of a patient one should have feel of doing phacoemulsification eb externo. For this remove various density of nuclei by SICS and try to emulsify them in a bowl of water. If you keep rubber cap of a injection vial in bowl and keep nucleus inside its cup , then this simulates as you are working in anterior chamber (AC).You should try different nuclei  and have the feel how easy or tough is to emulsify these nuclei. Other methods is using Kimura eye. This has been developed by a Japanese scientist. In this you can practice rhexis as well as actual phacoemulsification.

 The third method is to practice on goat’s eye. Get fresh goats eyes from a butcher. Keeping it under microscope, we make side-port incisions fill it up with OVD and do the rhexis. Make the tunnel Incision as Phacoemulsification and do some central sculpting so that it can accommodate human cataract nucleus. Open the eye from the other side as ECCE and put Nucleus previously removed by SICS. Close the incision by sutures. Now do the Phacoemulsification from the other incision we made for this purpose. This way it is closest to doing Phacoemulsification in human eye.

Another way of transit to phaco can be through “Modular Training” but it has to be carried out under supervision. Here the learning surgeon initially starts with I/A and starts getting friendly with the machine. Also he/she develops the feel of foot pedal in the meanwhile. Thereafter he learns to “eat up” the broken pieces of nucleus and finally takes up the job of breaking up of nucleus into pieces. Wound construction and capsulorhexis is done by the experienced surgeon till the last so that inadvertent complications can be managed well and there are lesser chances of conversion back to SICS/ECCE.

Start as you do in SICS. After doing rhexis and making incision, make a sclero-corneal  tunnel as you do in SICS. Enter the Anterior Chamber with kerotome and do not enlarge it. After Hydro-dissection and rotation of nucleus enter with Phaco-probe and make a deep trench in the center of nucleus. The depth of trench should be at least 2/3 of thickness of nucleus. Now enlarge the tunnel and withdraw the nucleus by SICS. Now check the depth of the trench, initially when you think you have made a deep trench it is not at all deep. This way you will know how deep the trench should be. In initial few cases of Phacoemulsification whole case can be done, starting like this without extending the sclera-corneal tunnel.

Now you are ready for Actual modern day Phacoemulsification.

After cleaning and draping, speculum is inserted. Two side port incisions are given at 9 o’clock and 2 o’ clock positions. Chamber is filled with OVD and a corneal tunnel incision is given at 11 o’clock is 2.8mm keratome. Length of tunnel ideally should be 2mm. Now rhexis is done through side port or main incision. Cortical cleavage hydro dissection is done to separate the capsule and cortex. Nucleus is rotated and a deep central trench is made in the nucleus. Now the nucleus is divided into two halves using two Sinskie hooks or one Sinskie hook and a chopper. Rotate the nucleus to bring one half at six o’ clock position.

Take phaco-probe and impale in the centre of nucleus half and from the other hand (Holding Sinsekie hook or chopper) divide this into two segments. Take the segments one by one and emulsify them. Now bring the other half at six o’ clock position and do the same. Now take the I-A hand piece and remove the cortical matter. Otherwise initially you can use Simcoe canulla to remove the cortical matter. Now fill the chamber with OVD and inject a foldable IOL in the bag. As the first haptic goes in the bag and later you dial the trailing haptic into the bag. Using I-A Canulla OVD is removed. Tunnel is hydrated on both sides. Side port incisions are also hydrated. Wound is checked for any leak.

There are few common problems that a beginner encounters and surgical pearls-

1.       Often, there is a premature entry with iris prolapse. It is suggested neither to postpone the case, nor to continue from the same port. Iris should be reposited, wound sutured and another site should be chosen for wound construction.

2.       Ballooning of conjunctiva is another annoying yet trivial issue. The wound should not be constructed too posteriorly and if it happens, the fluid can be expressed.

3.       Tight wound leads to hydration of cornea leading to visibility problems. The wound should be revised instantaneously.

4.       Hypotony and shallow chamber should be avoided at every step.

5.       Too much push and pull should be avoided with the injector. It is better to slightly enlarge the wound and push the IOL smoothly.

6.       Adequate size of capsulorhexis is of primordial importance in phaco. One should aim for a rhexis between 5 and 6 mm. It is suggested not to proceed with a compromised/ extended capsulorhexis in beginning. The case should be converted to SICS/ECCE.

7.       It must be clearly understood that our aim is not just to complete phacoemulsification, but to do a better surgery with better visual rehabilitation. Hence, corneal protection is a must and maneuvering in the AC must be away from cornea.

8.       Choice of main port (superio-temporal) is better. I would suggest an ECCE/SICS surgeon to initially go with superior main port to have a more habitual environment.

9.       Choice of I/A (coaxial/bimanual) is again personal. It is just a matter of comfort of surgeon.

10.   Capsulorhexis can be done either with cystitome or with Utratas’ forceps depending upon the surgeon’s comfort. Preferably it should be done through the side port under a good cohesive viscoelastic.

11.   Trying fancy things like direct/vertical chop, chip and flip, iris hooks/CTRs, polishing the capsule should be attempted after the sample size crosses the 100 mark. There would be innumerous occasions to innovate, improvise and improve.

12.   In case of large PCR, a sulcus PCIOL can be attempted by the beginner, but things like ACIOL should always be kept handy. Things like SFIOL should be taken up as a secondary procedure.

Never treat yourself as a beginner. Stick to your plan, give respect to the tissues and graduate step by step as you studied one class after the other. In no time you will see that you have become the master of the Phacoemulsification. All the best!

 Dr vipin Sahni

Kaushalya Devi Eye Institute

Pilibhit UP

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