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Role of manual small incision cataract surgery in Australia and developed nations

The many advantages of phacoemulsification have made it the gold standard for routine cataract surgery. There are, however, dense cataracts where, even in expert hands, phacoemulsification carries significantly higher risks; if the skill set is available, techniques such as manual small incision surgery (MSICS) may be the safer, more appropriate alternative. Several studies have shown both to be equally effective. In this issue of the journal, van Zyl, Kahawita and Goggin report the use of manual ‘small’ incision surgery (MSICS) for dense cataracts in Australia. They present a lucid case by demonstrating the safety and efficacy of this technique in a small number of dense cataracts. Thirty one of 38 patients (78%) achieved uncorrected visual acuity (VA) of 6/12 on day one after surgery, and 33 (83%) achieved corrected VA of ≥6/9 at 3 months. For patients who harbour such dense cataracts, presenting rather than corrected VA is the more appropriate outcome, but the lower end of the 95% confidence interval (CI) that we calculated – 67% for day one and 73% for 3 months – are reasonable. Complications were few, and we presume that clinically significant corneal oedema, the major worry with phacoemulsification in such cases, was not encountered. Although the authors compare some outcomes with other reports, their numbers are small and the CIs around their point estimates (we could not calculate them around the difference, which is more appropriate) show that some of their comparisons may not hold. The upper end for the CI for their 2.5% posterior capsule (PC) tear rate is compatible with a true rate of 13%, and hence could be worse than the report they compared it with, while their 7.5% posterior capsular opacity is compatible with a true rate of 21%. It is also important to remember that the term MSICS refers to a wide variety of methods and that the advantages/complications reported in the literature are technique-dependent. The technique described does not really fit the moniker of MSICS. The term MSICS is usually used for a ‘small incision’ with the objective of sutureless surgery. Accommodating an 8-mm sutured incision (just 2 mm less than the usual 10 mm incision used for standard extra capsular surgery) under MSICS is a bit of a ‘shrink’, but does not detract from the results. The suturing of incision by the authors may have contributed not only to the safety but also the decreased astigmatism after surgery. The Blumenthal technique that we use and recommend is based on sound surgical principles that keep the anterior chamber formed throughout the procedure, and the lens is hydro-dynamically expressed through a self-sealing 5to 5.5-mm incision. We do use viscoelastic for some stages of this surgery, but if costs are a consideration the entire operation can be performed without any viscoelastic and a secure sutureless incision is achieved 98% of the time. The wound does not leak even with pressure on the posterior edge, and the anterior chamber maintainer crucial to the technique ensures a fluid egress system much like with vitrectomy; both – in theory – protect against endophthalmitis. Likewise, lack of detrimental effect on the endothelium has been reported for the Blumenthal and the visco-expression, and cannot be extrapolated to all MSICS. MSCIS achieves results similar to phacoemulsification at a lower cost, and in the jargon of health economics it has ‘extended dominance’ over phacoemulsification. The current study reports a very low surgically induced astigmatism. Whether the generally reported 0.3–0.4 dioptre decrease in surgically induced astigmatism with phacoemulsification compared with MSICS is worth the extra cost can only be determined by calculating indices such as incremental net benefit to decide how much a society (developed or otherwise) is willing to pay for each 0.1 dioptre of reduction in cylinder. The authors have highlighted some indications for MSICS in a scenario where phacoemulsification is preferred practice; to this we add three more: the risk of nucleus drop is less with MSICS, it can be used safely with can opener capsulotomy or if the capsulorrhexis is not intact and it is easily combined with a trabeculectomy.