Learning micro incision surgery without the learning curve Ravi Thomas, MD; Shoba Navin, MS; Rajul Parikh, MS We describe a method of learning micro incision cataract surgery painlessly with the minimum of learning curves. A large-bore or standard anterior chamber maintainer (ACM) facilitates learning without change of machine or preferred surgical technique. Experience with the use of an ACM during phacoemulsication is desirable. Key words: Anterior chamber maintainer, micro incision cataract surgery, phacoemulsication Indian J Ophthalmol 2008;56:135-7 Introduction Surgery for cataract has witnessed a technological revolution and the advances continue. 1 The situation in India, a country that performs nearly four million cataracts extractions annually, is particularly exciting. 2 While extra-capsular and manual small incision surgery are the predominant techniques in current use, most ophthalmologists naturally aspire towards the technologically advanced phacoemulsication as a next step or preferred method. The technology and technique of phacoemulsication too have seen rapid advances. Safer machines with advanced sofware allow surgeons to perform cataract surgery safely with less and less ultrasound power. 3 The search for smaller and smaller incisions too continues. Towards this end, micro incision cataract surgery (MICS) is now becoming popular. 4 In order to decrease the size of the incision, MICS requires the use of a naked phacoemulsication needle, that is, a needle without the irrigating sleeve. The increased risk of incision burn is addressed by cold phaco technology. 5 The rollable lenses for insertion through this type of incision do not have the track record of usual foldable lenses; many using this technique would also insert an endocapsular ring to prevent shrinkage of the bag. The literature on the subject is sparse, with studies showing no real advantage of MICS over standard phacoemulsication. 6,7 There is, however, a market value for the latest in surgical techniques. There is also another, perhaps more legitimate need to master MICS: such a technique or modication thereof would be required to use the much- awaited injectable intraocular lenses. We describe an approach to achieve skill in MICS without any change in machine or phacoemulsication technique that can be achieved with the minimum of learning curves. Learning micro incision cataract surgery 1. Anesthesia: While there is no need to change your preferred technique of anesthesia, we make an argument for a formal block while in the learning stage. 2. The details described hereafer is applicable to right eye. A standard 20-gauge myringotomy blade is used to make a paracentesis incision in the upper temporal quadrant around the 10 oclock position [Fig. 1]. This incision is primarily used for the phacoemulsication. 3. The chamber is deepened with the preferred viscous or visco-elastic agent. 4. A continuous curvilinear capsulotomy is performed in the usual manner with a bent needle introduced through the paracentesis incision. The diameter of the capsulotomy is about 5.5 mm. 5. The myringotomy blade is used to make another paracentesis incision at 6 oclock [Fig. 2]. This incision is used to insert and xate the anterior chamber maintainer (ACM). Accordingly, we try to create an incision with an intra-stromal length of 1.5 mm. Alternatively, a paracentesis similar to the rst, but with a longer intra- stromal track is created at the 7 oclock position. An ACM [Fig. 3] atached to a botle of irrigating uid is inserted into the anterior chamber and the stop-cock is opened. The ACM can be the same as that used for standard Blumenthal Cataract surgery (Visitech Instruments Fl, USA; catalogue number: 58514). If you use this ACM, we would suggest that you also use an irrigating chopper. We prefer to use a slightly larger bore ACM designed by Professor Ehud Assia (Ccrnea infusion terminal; Ophthaltech; Switzerland). Even with this ACM, we prefer the extra irrigation from an irrigating chopper, which almost eliminates uctuations in chamber depth. We have used the regular chopper and technique too but then have to accept and be prepared for the slight anterior chamber uctuations that may occur. Whatever the ACM used, the higher the botle height, the beter. 6. A paracentesis incision is made approximately 90 degrees away from the incision that has been created for phacoemulsication. 7. The sleeve for the phacoemulsification needle is cut at its base. The naked phacoemulsication needle is introduced into the anterior chamber through the supero- temporal incision. The irrigating chopper or preferred instrument is introduced through the incision created for this purpose. Phacoemulsication is performed using the surgeons preferred technique. We use the stop and chop method [Fig. 4]. 8. The cortex is extracted using a single port aspiration LV Prasad Eye Institute, Hyderabad, India (RT, RP); Silome Eye Hospital, LV Prasad Eye Institute, Madanpalli, India (SN). Correspondence to Dr. Ravi Thomas, LV Prasad Eye Institute, Banjara Marg, Banjara Hills, Hyderabad-500 034, Andhra Pradesh, India. E-mail: rt@ravithomas.com Manuscript received: 22.02.07; Revision accepted: 29.06.07 Ophthalmology Practice