Converting from Phacoemulsification to Manual Small-Incision Cataract Surgery

Phacoemulsification is one of the most elegant methods of cataract removal and is also one of the safest. Though intraoperative complications have come down considerably since the early days, they do occur. There are times when continuing with phacoemulsification is no longer prudent. One of the commonest and feared complications is posterior capsule rupture (PCR) [1, 2], the management of which has been detailed elsewhere in this book. Experienced surgeons would in certain cases be able to continue with phacoemulsification in its presence. For beginning surgeons, this would be a recipe for disaster. When a PCR occurs early in the surgery, with most of the nucleus still present, it is safer to stop phacoemulsification and convert to a large-incision cataract surgery such as extracapsular cataract extraction (ECCE) or manual small-incision cataract surgery (MSICS). Up until the early 1990s, ECCE was the only option, but since Blumenthal [3] and later Ruit [4] described MSICS, this has become a safe and elegant alternative to continuing with phacoemulsification. Converting to a sutured ECCE wound is easy, but due to its large size, its structure is less secure, producing unpredictable postoperative astigmatism. An ECCE wound is open, and the anterior chamber (AC) remains flat, increasing trauma to the corneal endothelium and iris. Vitrectomy is ideally performed in a closed chamber, and an ECCE wound increases the degree of vitreous prolapse [5]. The MSICS wound has valve architecture (Fig. 19.1) that closes automatically during surgery, is more secure, does not open up with minor injuries, and produces a postoperative astigmatism that is more predictable. Vitrectomy is easier to perform in MSICS as the chamber is closed and remains deep. The method that has been described below can be used to convert to MSICS, when phacoemulsification becomes more challenging due to the density of the cataract, loss of the capsulorhexis, zonular dialysis (ZD), iridodialysis, corneal haze, or any other reason [6] necessitating discontinuation of phacoemulsification.