Manual small incision cataract surgery (MSICS): opening the door to a new strategy for addressing blindness

Glenn Strauss MD Mercy Ships

with thanks for contributions by James MacAllister, M.D.

Manual small incision cataract surgery (MSICS): opening the door to a new strategy for addressing blindness

Glenn Strauss MD Mercy Ships

with thanks for contributions by James MacAllister, M.D.

First high quality alternative to phacoFirst high quality alternative to phaco

An elegant sutureless ECCE procedure

It is ideal for situations where high quality, high volume output is desirable without high-tech instrumentation or equipment

Provides an alternative to standard ECCE when phaco is high risk.

An elegant sutureless ECCE procedure

It is ideal for situations where high quality, high volume output is desirable without high-tech instrumentation or equipment

Provides an alternative to standard ECCE when phaco is high risk.

Opens the door to new strategies in patient care Opens the door to new strategies in patient care

Ideally utilized as part of a team system to maximize efficiency as a single procedure approach to cataract surgery

Increasingly being utilized as an alternative tool for high risk cataracts

Integral part of a “funnel” strategy: screening, diagnostics, perioperative care, and surgical care

Has provided a new paradigm to address the problem of global cataract blindness

Ideally utilized as part of a team system to maximize efficiency as a single procedure approach to cataract surgery

Increasingly being utilized as an alternative tool for high risk cataracts

Integral part of a “funnel” strategy: screening, diagnostics, perioperative care, and surgical care

Has provided a new paradigm to address the problem of global cataract blindness

The funnel strategyThe funnel strategy

Utilizes key skills at each level of care Maximizes use of individual strengths Surgical yield in areas of low access is

approximately 15% of those being screened Criteria based: Decreased vision, nl pupils,

clear cornea If surgical goal is 3,000 cases, 20,000 will

need to be screened, 8,000 examined.

Utilizes key skills at each level of care Maximizes use of individual strengths Surgical yield in areas of low access is

approximately 15% of those being screened Criteria based: Decreased vision, nl pupils,

clear cornea If surgical goal is 3,000 cases, 20,000 will

need to be screened, 8,000 examined.

Flexible enough to be used with a variety of cataract pathologies

Quick, efficient surgery once mastered Rapid recovery

Minimal postoperative corneal edema• Minimal induced astigmatism (studies show

comparable to phaco) No sutures to be removed late Low cost per case

Flexible enough to be used with a variety of cataract pathologies

Quick, efficient surgery once mastered Rapid recovery

Minimal postoperative corneal edema• Minimal induced astigmatism (studies show

comparable to phaco) No sutures to be removed late Low cost per case

MSICS features:MSICS features:

A brief review of the technique as practiced on

Mercy Ships

A brief review of the technique as practiced on

Mercy Ships

Anesthesia Anesthesia

Routine peribulbar or anterior conal block- topical possible but less desirable

Lidocaine 2% 5cc alone usually sufficient because of short case time

Orbital compression helpful but does not require soft eye like ECCE

Routine prep and drapeTopical 5% betadine conj. drops and skin scrub,

isolate lashes

Routine peribulbar or anterior conal block- topical possible but less desirable

Lidocaine 2% 5cc alone usually sufficient because of short case time

Orbital compression helpful but does not require soft eye like ECCE

Routine prep and drapeTopical 5% betadine conj. drops and skin scrub,

isolate lashes

Adequate conjunctival/tenons dissection and wet field cautery

May use flame cautery if only option but avoid over cauterization

Dry carefully before scleral dissectionDry carefully before scleral dissection

Scleral incisionScleral incision

With fine toothed forceps hold limbal tissue and create 7.5 mm “frown’’ incision 1.5 mm from limbus at apex of the frown. 1/2 to 2/3 depth.

Initially it may be easier to make a simple linear incision

With fine toothed forceps hold limbal tissue and create 7.5 mm “frown’’ incision 1.5 mm from limbus at apex of the frown. 1/2 to 2/3 depth.

Initially it may be easier to make a simple linear incision

Sclero-corneal tunnel dissectionSclero-corneal tunnel dissection

Carefully follow the curve of the globe, slicing anteriorly approx 2 mm into clear cornea centrally

Take care to “straighten” the limbal junction angle A 3 to 3.5 mm tunnel length (half the length of the

crescent blade)

Carefully follow the curve of the globe, slicing anteriorly approx 2 mm into clear cornea centrally

Take care to “straighten” the limbal junction angle A 3 to 3.5 mm tunnel length (half the length of the

crescent blade)

Premature entry results in iris prolapse

Premature entry results in iris prolapse

Tunnel button hole is easily fixed with new tunnel plane

Tunnel button hole is easily fixed with new tunnel plane

Sweep to each side to create an 8 to 8.5 mm internal opening

Sweep to each side to create an 8 to 8.5 mm internal opening

Tunnel size can be titrated to the anticipated size of the

nucleus

Tunnel size can be titrated to the anticipated size of the

nucleus

Paracentesis at 9 o’clock with 15 deg blade- no anterior chamber

maintainer necessary

Paracentesis at 9 o’clock with 15 deg blade- no anterior chamber

maintainer necessary

Useful for reforming chamber

Keratome entry at anterior most extent of scleral tunnel

Keratome entry at anterior most extent of scleral tunnel

Sweep keratome left and right “floating” in the tunnel to fully open. If done well, chamber is maintained.

Sweep keratome left and right “floating” in the tunnel to fully open. If done well, chamber is maintained.

Consider supporting AC with viscoelastic

A B

C D

Careful 8 to 8.5mm “can opener” capsulotomy after filling AC with viscoelastic. CCC may be done for softer nucleus.

Careful 8 to 8.5mm “can opener” capsulotomy after filling AC with viscoelastic. CCC may be done for softer nucleus.

A B

C D

With capsulotomy needle inserted into nucleus, “rock and roll”, rotating and lifting the nucleus from the capsular bag

With capsulotomy needle inserted into nucleus, “rock and roll”, rotating and lifting the nucleus from the capsular bag

With lens loop, depress posterior lip of scleral tunnel and allow nucleus to glide out through the incision. (must be large enough)

With lens loop, depress posterior lip of scleral tunnel and allow nucleus to glide out through the incision. (must be large enough)

Tunnel acts hydro dynamically like a funnelTunnel acts hydro dynamically like a funnel Nuclear material never contacts

endothelium Facilitates increased efficiency of

nucleus removal Improves safety in high risk cases

(trauma, zonular instability, partially dislocated cataracts, hypermature cataracts, previous surgery)

Nuclear material never contacts endothelium

Facilitates increased efficiency of nucleus removal

Improves safety in high risk cases (trauma, zonular instability, partially dislocated cataracts, hypermature cataracts, previous surgery)

Gently depress post. lip of tunnel to milk out remaining lens material while tilting the globe by holding the limbus at 6 o’clock

Gently depress post. lip of tunnel to milk out remaining lens material while tilting the globe by holding the limbus at 6 o’clock

Remove remaining cortex using suck and wash approach (dragging cortex to center of pupil and releasing).

Standard Simcoe is not ideal instrument- designed for limbal incision. Chamber maintenance is dependant on making inner opening the pivot point. The eye is now ready for lens implantation.

Fill anterior chamber with methylcellulose or air.

Remove remaining cortex using suck and wash approach (dragging cortex to center of pupil and releasing).

Standard Simcoe is not ideal instrument- designed for limbal incision. Chamber maintenance is dependant on making inner opening the pivot point. The eye is now ready for lens implantation.

Fill anterior chamber with methylcellulose or air.

Insert IOL and remove methylcellulose. Inject BSS to moderate pressure. AC should remain formed. No conj closure needed.

Insert IOL and remove methylcellulose. Inject BSS to moderate pressure. AC should remain formed. No conj closure needed.

Complete the operation with routine antibiotics +/- steroid. Remove the speculum by lifting out inferior blade first

Complete the operation with routine antibiotics +/- steroid. Remove the speculum by lifting out inferior blade first

Other techniques for MSICSOther techniques for MSICS ACM Fish hook Plastic glide for nucleus

ACM Fish hook Plastic glide for nucleus

Phaco nightmare

ResultsResults

0

50

100

150

200

250

P LHM

C F - 20/200

20/160 - 20/100

20/80-20/30

P re Op V is ion

P os t OpV is ion

0

50

100

150

200

250

P LHM

C F - 20/200

20/160 - 20/100

20/80-20/30

P re Op V is ion

P os t OpV is ion

ResultsResults

0102030405060708090

100

Nu

mb

er o

f P

atien

ts

< -2 0+ /-2

3-6 7-11 12-16

17-21

22-27

27+

C hang e in vis ion / L og MAR lines

C hang e in vis ion

0102030405060708090

100

Nu

mb

er o

f P

atien

ts

< -2 0+ /-2

3-6 7-11 12-16

17-21

22-27

27+

C hang e in vis ion / L og MAR lines

C hang e in vis ion

Pre and post op visual functionN

o o

f p

atie

nts

Improvement of vision by age: 30 to 40 y/o success are primarily traumatic cataracts.

Ave

rage

num

ber

of li

nes

impr

oved

Age of patient * p<0.05

% o

f pa

tient

sReported success rates from developing countries

Barriers to implementationBarriers to implementation

Cost: low cost does not mean NO cost Local regulatory issues Lack of clear, positive motivations for the

team and surgeon Medical community resistance: MSICS is

gaining credibility Ophthalmic corporate resistance: less

dependence on high tech equipment Surgeon skills

Cost: low cost does not mean NO cost Local regulatory issues Lack of clear, positive motivations for the

team and surgeon Medical community resistance: MSICS is

gaining credibility Ophthalmic corporate resistance: less

dependence on high tech equipment Surgeon skills

For discussion: how to take advantage of this approach for the benefit of South Africa

Brief review of recent RAAB study Eastern Cape

For discussion: how to take advantage of this approach for the benefit of South Africa

Brief review of recent RAAB study Eastern Cape

Rapid Assessment of Avoidable Blindness in Eastern Cape Province

of South Africa

Rapid Assessment of Avoidable Blindness in Eastern Cape Province

of South AfricaS.Saravanan of

PRASHASA ConsultantsOn behalf of FHFSA

S.Saravanan ofPRASHASA Consultants

On behalf of FHFSA

SummarySummary The all-age prevalence of blindness for Eastern

Cape Province of South Africa is estimated to be 0.58%;

The all-age magnitude of blindness for EC Province is estimated to be 38,354 people out of a population of 6.57 million;

Avoidable causes of blindness accounted for 73.2% of blindness, 86.1% of severe visual impairment and 85.7% of visual impairment.

The all-age prevalence of blindness for Eastern Cape Province of South Africa is estimated to be 0.58%;

The all-age magnitude of blindness for EC Province is estimated to be 38,354 people out of a population of 6.57 million;

Avoidable causes of blindness accounted for 73.2% of blindness, 86.1% of severe visual impairment and 85.7% of visual impairment.

SummarySummary Cataract (62.2%) and sequel related to

cataract extraction (1.2%) accounted for 63.4% of all causes of bilateral blindness;

Posterior segment disease is responsible for 31% of bilateral blindness;

36.1% of people with bilateral cataract VA<3/60 had surgery and 18.9% at VA<6/18.

Cataract (62.2%) and sequel related to cataract extraction (1.2%) accounted for 63.4% of all causes of bilateral blindness;

Posterior segment disease is responsible for 31% of bilateral blindness;

36.1% of people with bilateral cataract VA<3/60 had surgery and 18.9% at VA<6/18.

Results – Cataract Surgery CoverageResults – Cataract Surgery Coverage

Cataract surgical coverage: 36.1 % of people with bilateral cataract blind (VA<3/60) had surgery and 18.9 % at VA<6/18;

Cataract surgical coverage: 36.1 % of people with bilateral cataract blind (VA<3/60) had surgery and 18.9 % at VA<6/18;

Results – Cataract Surgery OutcomeResults – Cataract Surgery Outcome

22 % of the 109 eyes that had undergone cataract surgery had a poor outcome (i.e VA<6/60) with best correction;

Best corrected, good visual outcome (>6/18) was estimated as 64.2%;

109 eyes had cataract surgery with 79% having an IOL implant.

22 % of the 109 eyes that had undergone cataract surgery had a poor outcome (i.e VA<6/60) with best correction;

Best corrected, good visual outcome (>6/18) was estimated as 64.2%;

109 eyes had cataract surgery with 79% having an IOL implant.

Results – Cataract SurgeryResults – Cataract Surgery 99% of all surgeries performed were at

public health facilities; 19.3% were using spectacles after cataract

surgery.

99% of all surgeries performed were at public health facilities;

19.3% were using spectacles after cataract surgery.

KEY FINDINGS - ProductivityKEY FINDINGS - Productivity Demand and Supply mismatch. Number

of surgeries not enough to match “incidence”.

Low surgical Productivity CSR in Eastern Cape province = 1022 Required CSR = 4,000

“Unaware of treatment”(63.7%, SVI-57.8%)

Demand and Supply mismatch. Number of surgeries not enough to match “incidence”.

Low surgical Productivity CSR in Eastern Cape province = 1022 Required CSR = 4,000

“Unaware of treatment”(63.7%, SVI-57.8%)