 Hello my name is Jeff Petty. I'm an assistant professor at the Moran Eye Center in Salt Lake City, Utah. I'm also the residency program director there as well. Our topic today is going to be small incision cataract surgery, a manual form of cataract surgery, particularly important for the developing world. Getting right to a video kind of introducing this. This is a video Dr. Bidya Punt at the Getta Eye Hospital in Nepal. The reason I'm choosing to use his video is because he's very fast and efficient surgeon. For beginning or even intermediate, surgeons doing SICS, your surgeries will be much longer. Unedited, this is going to be about four minutes. So first, Dr. Punt has made a scleral groove and then followed by a scleral tunnel. Again, it's important to understand this tunnel is partial thickness, so he's just tunneling up through the sclera and the cornea. He has not yet entered the eye. The anatomy of the tunnel is such that it will fan out to each side so that the internal wound will be larger than the external wound. And there that's where he's actually entering the anterior capsule. As with all surgeries, if you're entering the anterior capsule, you want to put some biscoelastic in the eye to stabilize the anterior chamber. He does the same thing. So continuing on, now he'll cut that opening into the anterior chamber and he'll fan out to the left. Again, leaving roughly a 10 to 11 millimeter opening on the inside of the cornea, funneling down to a 6 millimeter opening in the external cornea. Right here, he has just entered the anterior capsule. This is to use an envelope capsuleotomy. There are many different types of capsuleotomy techniques you can use with this type of surgery. An envelope is one type where you make a horizontal linear incision in the proximal end of the the capsular bag. So now, he's irrigated out some of the cortical fluid, put in some biscoelastic to elevate the nucleus up, and now this is a fish hook. The fish hook actually enters under the lens and then he removes the remainder of the nucleus. So at this point in the surgery, we're roughly a minute and a half, two minutes into the surgery. The vast majority of the surgery, the time is actually, if there was one step that time is devoted to, it's to the cortical cleanup of the surgery. And it's an important reminder that just getting the lens out is not cataract surgery. Removing all the cortical material, particularly in the developing world, where they will not or may not have access to YAG lasers for posterior capsule pacification treatment. So this instrument is a Simcoe cannula. It's a manual way to have irrigation and aspiration completed. As soon as all of the cortex is cleaned up and inspected, the next step will be actually injecting the lens. As with really any type of cataract surgery these days, you would of course put in biscoelastic into the capsular bag to inflate the bag and inflate the anterior chamber prior to putting a lens in. And indeed, that's what he's going to do here. The Simcoe cannula of note, one important aspect about it, the irrigation port is at the end as well as an aspiration port. The aspiration port is controlled manually with a syringe. So rather than using a foot pedal like many phaco surgeons would be used to for aspiration, he actually is just manually aspirating with a syringe. So the biscoelastic has gone into the capsular bag and at this point you'll see a single piece PMMA lens. This is a lens that is manufactured either in Nepal or in India and in one step he dials that in. Now the anterior capsule is still present on the eye and that must be removed before the surgery is finished. So he's taken long vana scissors, made two cuts to the right and left and now he'll actually engage the anterior capsule with the Simcoe cannula aspirating and he's removed the roof of the anterior capsule. So the lens is now comfortable. A really important surgical principle that for someone as elegant as Dr. Pond that's very important is you'll notice that nothing inside of the eye is fast. Everything inside of the eye is slow, controlled and very elegant and yet start to finish again. This is a surgery that will take him less than five minutes. Being fast in the eye is not the way to become an efficient surgeon but eliminating wasteful steps. So he's aspirated the remainder of the biscoelastic out and at this point you'll see as he exits he inflates the chamber. This is a self-sealing wound as constructed and then there there will be various ways for conjunctival closure. In this particular case with the superior wound he is injected some steroid and some antibiotic. So continuing on a few things important to understand small incision cataract surgery is the name of the surgery or six you may hear it called but small is a relative term. A size is a relative term. This is a much larger incision than a FACO incision. This is not a small incision compared to FACO. However compared to old traditional extra caps or cataract surgery this is a small incision. I think it's a bit of a misnomer though to say that it's small incision. A better acronym would be suture less extra caps or cataract surgery. The acronym ends up being a little better or easier to remember for many of us of sex so if I do say sex in this lecture I'm referring to this surgery to nothing else. So a really important question as you're beginning to understand is what is a more difficult surgery to learn suture less extra caps or cataract surgery or FACO. This is a group of residents at the Tilganga Eye Hospital in in Kathmandu Nepal and for these residents they will tell you FACO emulsification is the most difficult surgery that they will attempt to learn during their training. These are our residents at the Moran Eye Center. If you ask these residents what the most difficult surgery to learn between the two is they will tell you it's suture less extra caps or cataract surgery simply because here we train in FACO. They will do three to four hundred FACO emulsification surgeries before they ever start doing the suture less extra caps or cataract surgery and that volume to them makes FACO easier whereas the the surgeons and the residents at the Tilganga Eye Hospital they don't learn FACO until the very end and they do a lot of suture less extra cap so I don't think one is easier than the other it just is a matter of having enough volume and great teachers to teach you. There are several important steps for the surgery. I'm not going to cover all of them in this talk. In future talks we'll cover each individual aspect but if there was one single key I would say to the surgery it's the wound. So as you review this list you'll see there are many steps. We're not going to cover all of those steps in detail because as you become competent surgeons eventually you'll understand when you need to put in viscoelastic to keep the anterior chamber inflated what the logical next step would be. You don't need a list to know how to do surgery you just can logically think through it. I'd like to just show the wound one more time again the wound being the important kind of the key to this. If the wound is not self-sealing, if the wound is not placed correctly, you really oftentimes have to abort the surgery altogether. So simply there's a groove again this can be six to eight millimeter groove externally and then a long scleral tunnel. The scleral tunnel itself you'll begin your groove centrally roughly two millimeters back from the limbus and then you'll tunnel and groove into the clear cornea two millimeters in the middle out to the side where the tunnel is much longer. The tunnel may be as long as six even eight millimeters long to the side and then an important aspect is making sure you're at the distal end of your tunnel before you enter the anterior chamber. You can imagine if you enter prematurely into the anterior chamber at the level of the iris you'll be dealing with a case you may need to abort or a case where a chance of an iris complication is very high. So in a focal points module put out by the academy in 2012, Jeff Tabin and Michael Feilmeyer gave a great overview of this procedure. You will need some sort of textbook perhaps something like the focal points module can be adequate for you initially but eventually an actual textbook would be advisable. What you see here is with permission from Jeff Tabin a graphic illustrating the actual dimensions of this surgery of particularly of the wound. The V here in the center is one form of capsuleotomy. That capsuleotomy it's not mandatory that you use that again there are multiple types but that gives you a great guide for the actual incision. Potential complications of the wound if you enter too prematurely at the level of the iris you will have iris complications and you'll likely have a leaky wound. If you make your tunnel too thin you can begin to come up through the roof of your tunnel and at that point you create sort of a buttonhole complication. A very common complication is a wound that's too small. As you try to remove a large nucleus the lens get stuck. You can also lacerate the lateral margins of your wound. Remember of course the globe is a globe it's not flat and as we're creating our tunnels if we don't compensate for the curve of the eye we can actually come to the side and just cut directly out of the lateral edges of the wound making it an incompetent and unusable wound. And again a wound leak can occur from many different aspects of a poorly constructed wound. Just like to show one separate video but the same technique. This is just a single pass with a crescent blade. The easiest type of crescent blades for this type of surgery is a bevel up crescent that will help you to maintain the plane that you're trying and avoid getting into the wrong plane. Simply switching to a bevel down or a double bevel crescent will change the way that the instrument will behave within the eye. Again waiting until he's at the distal end of the tunnel before he enters inserts his visco elastic again and then comes in and he'll cut to the left expanding that opening very wide inside creating that nice funnel shape that allows for the self-sealing lip. It's not so much the length of the tunnel from the base to the entry that makes it self-sealing it's the fact that it has an internal lip of cornea actually a big 10 millimeter lip of cornea that when pressurized can flip up and seal the wound. These are my references. I myself have learned from many mentors Sandeuk Rui but particularly Dr. Bidya Pond has been my mentor. The most important thing you can do to learn the surgery is to get a good mentor. You can't teach this to yourself on your own safely with patience. We'll follow up with some additional important aspects to this surgery. Once again thank you for tuning in. This is a challenging surgery finding a mentor is the most important thing you can do to really learn it well and I commend you for challenging yourself in learning this surgery. Thank you.