Steps of Small Incision Cataract Surgery (SICS)
Small Incision Cataract Surgery (SICS), also known as Manual Small Incision Cataract Surgery (MSICS), is a highly effective technique particularly valuable in high-volume settings and for mature cataracts, with outcomes comparable to phacoemulsification but with shorter surgical time and lower cost. 1, 2
Preoperative Preparation
Patient Setup:
- Clean the corneal surface with balanced salt solution and remove excess fluid so the surface is moist but not wet 1
- Apply topical anesthesia (can use topical with intracameral lignocaine as an alternative to peribulbar block) 3, 4
- Cleanse surrounding skin and eyelashes of the operative eye 1
- Apply eyelid speculum for optimal corneal exposure 1
- Mark the cornea to facilitate proper orientation during closure 1
Surgical Steps
1. Incision Creation:
- Create a superior scleral tunnel incision (typically 6-7mm) 5, 2
- The incision is self-sealing and sutureless in most cases 1
2. Anterior Capsulotomy:
- Perform continuous curvilinear capsulorhexis or can-opener capsulotomy depending on surgeon preference and cataract density 2
3. Hydroprocedures:
- Perform hydrodissection to separate the nucleus from the cortex 2
- Perform hydrodelineation if needed for dense cataracts 2
4. Nucleus Delivery:
- Prolapse the nucleus into the anterior chamber using viscoelastic 2
- Deliver the nucleus through the scleral tunnel incision using a combination of pressure and manipulation 2
- This is the key distinguishing step from phacoemulsification, as the nucleus is removed intact rather than emulsified 1
5. Cortical Aspiration:
- Remove residual cortical material using irrigation-aspiration 2
6. IOL Implantation:
- Implant foldable or rigid intraocular lens into the capsular bag 1, 5
- Rigid IOLs may require slight enlargement of the incision 2
7. Wound Closure:
- Ensure the incision is self-sealing 1
- Apply sutures or sealants only if needed for adequate closure 1
8. Postoperative Medication:
- Instill topical antibiotic and corticosteroid drops 1
- For patients with uveitic cataracts or history of inflammation, consider oral prednisolone 1 mg/kg body weight starting 7 days prior to surgery 5
Key Technical Advantages
Surgical Efficiency:
- Mean surgical time is significantly shorter than phacoemulsification (approximately 10.8 minutes versus 13.2 minutes) 5
- Particularly advantageous in high-volume settings and humanitarian campaigns where surgical efficiency is critical 2
Clinical Outcomes:
- Produces comparable visual acuity outcomes to phacoemulsification, with 88-90% of patients achieving corrected distance visual acuity of 20/60 or better at 6 months 5, 6
- Mean surgically induced astigmatism is slightly higher than phacoemulsification (1.16D versus 0.86D) but still clinically acceptable 5
- Significant improvement in vision-related quality of life, with approximately 88% of patients achieving visual function scores over 75% postoperatively 6
Important Clinical Considerations
Optimal Indications:
- Particularly effective for mature and hypermature cataracts where phacoemulsification may be more challenging 2
- Preferred technique in settings with limited access to phacoemulsification equipment 1, 5
- Cost-effective option in economically disadvantaged regions 1
Anesthesia Options:
- Traditional peribulbar block can be used 5, 3
- Minimalistic approach using 1.5-2 mL subconjunctival anesthetic with intracameral supplementation is effective and avoids complications of traditional blocks 3
- Topical anesthesia with intracameral 0.5% lignocaine is safe and patient-friendly, with 95% of patients reporting mild to no pain 4
Complication Rates:
- Comparable complication rates to phacoemulsification for macular edema, persistent uveitis, and posterior capsule opacification 5
- Lower rate of surgical complications such as iris prolapse and posterior capsule rupture compared to traditional extracapsular cataract extraction 1
Learning Curve: