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Manual Small Incision Cataract Surgery : 



Wound construction

  • Placement
  • Length
  • Depth

Placement:  Ideal- 2-3mm from posterior border of blue line

Anterior incision: 

    • Poor self sealing effect
    • Wound leak
    • Against the rule astigmatism 

Apply suture.

Posterior incision:

    • Wide tunnel
    • Bleeding
    • Premature entry

Makes nucleus delivery difficult.  Instrument manipulation difficult.

For premature entry : Suture.


Incision length
Two factors:

  • size & hardness of the nucleus
  • size of the IOL

Short incision

    • Difficult nucleus delivery
    • Endothelial damage
    • Iris damage

Enlarge Incision with Keratome.

Long incision:

    • Poor approximation -- wound leak
    • Induced astigmatism

Apply Suture. 


Hold the globe properly before attempting tunneling

Incision depth:    Ideal -- 1/2 to 1/3

  1. Button holing -- superficial dissection of the sclera
    • Make a deeper dissection from the opposite end
  2. Premature entry -- new dissection started at a lesser depth
    • If needed suturing of the tunnel at the end
  3. Scleral disinsertion -- very deep groove incision causes this
    • Use radial sutures to secure the edges of incision on either side of the scleral groove
    • Can be prevented by using guarded blades

Click here for a video on difficulty in holding the globe

Click here for a video on button holing

Click here for a video on premature entry


Complications of Wound Construction

complications 1


Descemet's Stripping

  • While injecting fluid in to AC if canula tip placed in corneal lamellae
  • Injected fluid:  Interlamellar hydro dissection of cornea creating a space between the deep stroma and Descemet's
  • Some times can be mistaken for anterior capsular flap
  • Management:  Prevented by careful instrumentation
    • In small Descemet's stripping:  inject air bubble beyond point of stripping
    • In lower quadrant: use viscoelastics
    • In large Descemet's stripping:  full thickness corneal suture


  • Too central:  DM stripping
  • Too peripheral:  Bleeding
  • Too small:  DM stripping
  • Too large:  Leakage


Peripheral extension may occur:

  • Re-form AC with viscoelastic
  • Grab the flap close to the advancing tear & pull centrally
  • For better control -- use rhexis forceps
  • Raise opposite flap by making a small incision in capsule with Vannas scissors, continue in the reverse direction
  • If all fails, convert to can opener

Small rhexis:  difficult nucleus prolapse & cortex aspiration

    • enlarge rhexis by 2 or 3 relaxing incisions

Large rhexis:  problem for in the bag placement

    • may cause in/out situation

Click here to see a peripheral extension of rhexis


Hydro Dissection

If done forcibly at any one site:  grave risk of undue pressure on the posterior capsule; causes posterior capsular rupture and nucleus drop.  In 20 to 25% of cases of posterior polar cataract we see congenital pc dehiscence.  Do not do hydro dissection and do hydro delineation.

Nucleus Prolapse

  • Very important step in manual SICS
  • Points to note:
    • corneal status
    • pupillary size
    • cataract density
    • integrity of zonules
    • size of the tunnel
  • Difficult in very soft cataracts & in nuclear sclerosis
  • Proper hydro dissection
  • Good grip of Sinskey's hook
  • If proper attention is not paid, the following complications may occur:
    • endothelial damage
    • iridodialysis
    • damage to the iris
    • zonular dialysis
    • posterior capsular tear

Nucleus delivery

Inadequate size of the tunnel can lead to:

1.  Endothelial damage
2.  Iris sandwich when 6 o'clock iris gets trapped between the vectis inferiorly & nucleus superiorly

In case of a problem, do not hesitate to enlarge the tunnel

Click here to see a difficult nucleus prolapse and delivery


Iris sandwich

iris sandwich



During initial steps:

  • More posteriorly placed incision
  • Deeper placed incision

During later steps:

  • Iris injury during nucleus delivery


  • Proper placement of the tunnel
  • Taking care of iris
  • Careful placement of the vectis
  • Adequate viscoelastics

Leave air at the end of surgery

Steroids, cycloplegics, antiglaucoma medications

Click here to see rigid pupil and hyphema


Iris Injury

Direct injury to the iris:

  • Sphincter tears:  rigid pupil (pxf,comp.cat); I/A of cortex 
  • Iridodialysis:  during nucleus
    • If < 1clock hr, leave alone
    • If  > 1clock hr, McCannel suture
  • Iris prolapse:  loss of pigment, flaccidity, bleeding, pupillary irregularities & C.M.E
  • Rx
    • careful repositioning
    • cortex wash thru paracentesis, peripheral iridectomy
    • iris repair
    • suturing the tunnel
    • leave air
    • steroids & NSAIDS post op


Zonular dialysis

Prior to surgery in: 

  • pre existing trauma
  • pxf
  • Marfan's syndrome

During surgery: 

  • Traumatic capsulotomy
  • Excessive maneuvering of nucleus
  • Accidental aspiration of ant / post capsule
  • Excessive force in dialing the implant


  • If in single quadrant - PC lens in sulcus
  • If in > 2 quadrants - whole cortex & capsule removed - miosis - AC lens


Posterior capsular tear

Most common & most significant complication

Occurs during:

  • Forceful hydro dissection
  • During nucleus prolapse  (rupture of PC)
  • During cortex aspiration
  • Excessive manipulation of hard nucleus


  • Do not hydrate the vitreous [ lower the infusion ]

If no vitreous disturbance:

  • Seal tear by viscoelastic above PC plane
  • Do dry aspiration of cortex

If vitreous disturbance:

  • Tamponade with air, viscoelastic
  • Automated vitrectomy
  • Aspiration of cortex near rent margin last


Residual Cortex

Difficulty in removal of cortex in:

  • Inadequate pupillary dilatation (rigid/small pupil)
  • Defective I/A cannula
  • Positive vitreous pressure
  • Small capsulorhexis
  • PC tear


  • Good hydro dissection
  • Thorough cortex wash [small pieces can be left behind if risk of pc tear]
  • Use side port for 12 o'clock cortex 


Intraoperative miosis (constricting pupil)

  • Excessive handling of iris during nucleus delivery
  • Excessive instrumentation

Results in:

    • Difficulty in prolapsing the nucleus into AC
    • Increased risk of iris damage
    • Difficulty in removal of residual cortex & epinucleus -- increased risk of posterior capsular tear


    • Avoid/reduce iris touch
    • Irrigate the posterior surface of the iris
    • Use small pupil strategy


Dropped nucleus

  • Dreadful complication
  • Managed immediately or as secondary procedure


    • Inject viscoelastic under the nucleus
    • Additional support with vectis
    • Enlarge the section
    • Slowly take out

Once sunken in:

    • Do not fish it out
    • Thorough anterior vitrectomy & cortex cleanup
    • Refer to a vitreo-retinal specialist


Positive vitreous pressure

  • Manual SICS -- Less prone for this complication
  • Manifests by -- Anterior displacement of PC & iris AC collapse
  • Makes the surgery difficult by:
    • Less room available for maneuvering
    • Difficult cortex aspiration
    • Chances of iris prolapse
    • Danger of inadvertent PC tear
  • Identify the cause:
    • Speculum/instrument pressure on globe
    • Excessive pull of bridle suture
    • Poor facial block, obese patient
    • Valsalva maneuver (coughing & straining)
    • Large volume of anesthetic solution
  • Management:
    • Check speculum/bridle suture
    • Ensure that the patient rests comfortably
    • Use viscoelastics liberally to form AC
    • Use side port for cortical cleanup (alone adequate to form AC & capsular bag)
    • Reposition the iris gently, suture the tunnel
    • If choroidal hemorrhage suspected, stop -- loss of red glow
    • Ensure that all wounds are tight
      • ? I.V. mannitol


Expulsive Hemorrhage

  • Rare in manual SICS
  • Manifests as: 
    • Tissue prolapse through the wound
    • Loss of red glow
    • Hard globe
  • The eye is in immediate danger of becoming blind due to CRAO and consequences of expulsive hemorrhage
  • Management:
    • No matter at which of stage of surgery
    • Stop the surgery, suture the incision
    • When IOP comes down, assess posterior segment


The successful management of intraoperative complications requires a combination of:

  • Early recognition
  • Knowledge
  • Skill
  • Judgment


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