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Suggestions From MSICS Course ( SEE ) September 2016

Don’t believe everything you think.

Did you see the September 2016 National Geographic magazine? Cover story on -- The End of Blindness Winning The Fight To See? The article talked about blindness in the developed world as well as the developing world. Lots of reasons for the reduction. In the emerging world, two big reasons is the incidence of extreme poverty has decreased slightly in low-income countries and the efforts of IAPB / WHO / Vision 2020. The IAPB is a large umbrella organization of almost all eye organizations that have any interest in the reduction of blindness worldwide. Check out the web site for International Agency for the Prevention of Blindness ( IAPB ) and also Vision 2020 – The Right To Sight. The IAPB meets every four years. It’s like homecoming for many eye health workers who have donated their professional lives to the reduction of blindness in the developing world. The club is getting bigger. We are always looking for “new members.” The next IAPB meeting happens to be October 2016 in Durban, South Africa. You are welcome.

I quite recently was a speaker at the Surgical Eye Expedition ( SEE ) course in Santa Barbara, Ca on Manual Small Incision Cataract Surgery ( MSICS ). SEE holds this popular one day course / wet lab in Santa Barbara, Ca usually twice annually and also elsewhere.

The other speakers were Dr. Jeff Rutgard and Dr. Janak Shah from Mumbai. Mrs/ Dr. Shah also helped / instructed in the wet lab. I would like to go over some of the suggestions / tips made at this course. The participants ranged from ophthalmic surgeons already quite knowledgeable in MSICS to novices.
Many videos of this cataract procedure are available on YouTube. Would strongly advise having a look. The three “ new “ steps for the accomplished phaco surgeon are wound construction, nucleus prolapse into AC and finally nuclear delivery out of eye. There are many variations / techniques on how to do any / all of these three steps. Again check out YouTube --- videos / talks.
Dr Rutgard went through each step of MSICS and showed his ” P “ suggestions: “Prior Proper Planning Prevents Poor Performance”. This might be good advice for more than just MSICS. Dr. Shah mentioned briefly his volunteer outreach program with his own safari vehicle --- all at his own expense. It’s amazing how many people are “ doing good “. Get on board.
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 ) Then 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. Then 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.
Ok, I will continue my MSICS course suggestions with my next blog.
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

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