Which capsulotomy to use in SICS?

Manual small incision cataract surgery (MSICS) is a gold standard for high-volume cataract services in developing countries. Since recently (with the rise of global ophthalmology concept) it has become part of the best ophthalmology training programs in the US and across the world. It is an absolutely brilliant and gentle technique, which is especially suited for premature, mature and hypermature cataracts, as well as traumatic and congenital cataracts. But one can also apply the same technique to operate on immature cataracts. Here it won’t be so fast, as the aspiration of sticky cortex will take its time with Simcoe cannula. Nevertheless, all the stages are doable.

There are differences in capsulotomy diameter, which one needs for “normal” immature cataracts (~5-6 mm) and for hypermature cataracts (up to 9-10 mm!). In mature cataracts one has to use a dye (trypan blue), but also often to carefully decompress an elevated intralenticular pressure (which often fails and leads to capsular tear and/or “argentinian flag”-style tears)! This makes capsulotomy (and capsulorhexis as one of them) in mature cataracts more complex if compared to the one in immature “transparent” cataracts.

For MSICS I personally preferred mainly a so-called “can-opener” type of capsulotomy, as it is a) easier, b) faster, and c) safer. Once I had realized these benefits, I switched to this technique almost invariably. Can-opener is best for big mature nuclei and also for Morgagnian cataracts. I am, however, aware, that can-opener is almost always not a good option for phaco. At the same time I found continuous curvilinear capsulorhexis (CCC) technique in transparent (immature) cataracts pretty easy to perform in comparison to intumescent hypermature cataracts. However, CCC is also possible by MSICS on mature cataracts. One can do it through both a tunnel or a paracentesis. A tunnel offers greater maneuverability, a paracentesis offers more stable anterior chamber.

For CCC in MSICS one can employ a) insuline syringe needle, b) Utrata forceps (gives the best control over rhexis!) and c) McPherson tying forceps. The latter is non-toothed and is a sort of improvisation, when the correct forceps is inavailable (often the case in Tropics!). In this video I depicted typical variants of CCC by mature and hypermature (and intumescent and Morgagnian!) cataracts, both uncomplicated and complicated cases. The can-opener technique is presented in two cases here and also in the other video of this channel.

* Some of the videos were screened at the earlier stage of my MSICS career. Some of the capsulotomies depicted here could have been managed better, and do not necessarily represent the best possible surgical technique. After I had bought Utrata capsulorhexis-forceps during my trip to the USA in early 2017, I never used McPherson for this purpose anymore. So, I highly recommend to purchase Utrata early in your MSICS career. The video will however be a good one for the MSICS beginners in the tropics, who often have to tackle the complex intumescent lenses with suboptimal instruments, and who still have the right to do mistakes 🙂 I would anyways appreciate your (also critical) comments.

Those of you, who just start with MSICS – Keep it up!

Thanks for watching!

Results of MSICS Cataract Surgical Camps – A Case of Tansania

Interesting paper on results of eye surgical camp in Tansania. The results of 42 surgeries show that only 14% of patients at the postoperative day 5-9 have gotten a visual acuity > 0,3. That is unusually low in comparison to our experience in Zambia and to the results published elsewhere in the literature. The case may be due to, as indeed stated in the paper, the highly complicated cases (i.e., also poor selection of cases), and occasionally the quality of the technique and instruments used.

Sumbawanga Augencamp follow-up Studie 2019


A total of 42 postoperative patients from the eye camp could be examined within 5–9 days after cataract sugery. The following parameters were found: median postoperative visual acuity 0.26, spherical equivalent −2.82 dpt, astigmatism −2.2 dpt, axis 113°. Visual acuity >0.3 in 14.2% (WHO 80%), vision 0.1–0.3 in 62% (WHO 15%), vision <0.1 in 23.8% (WHO 5%). Prolonged healing time and intraocular irritation in 29% of the cases.


Although the vision improved, the results are sobering when taken in the context of the WHO guidelines. The postoperative refraction showed a myopic shift and an high level of astigmatism. The reasons are manifold: ocular comorbidities, limited diagnostic and therapeutic possibilities in a nonclinical setting. Other factors are the kind of training of the staff in the camp, the difficult circumstances and advanced findings. Consideration of the results of this study is imperative to be able to measure the quality of the work and to create the potential to make future improvements.

When would one operate cataract in Africa?

There is a good retrospective study from Nigeria showing that trends to operate only the advanced stages of cataract persist in Sub-Saharan Africa. That means that a patient with cataract would typically get his cataract removed only when they are blind (i.e. 0,05 or 3/60 and beliw, HM, LP etc.). In this context it is important to remember, that MSICS technique of cataract surgery is safer in premature and matute stages of cataract, which can influence the willingness to operate among surgeons.

Ther Adv Ophthalmol. 2019 Jan-Dec; 11: 2515841419886451.
Published online 2019 Nov 13. doi: 10.1177/2515841419886451
PMCID: PMC6854760
PMID: 31763621
Preoperative visual acuity of cataract patients at a tertiary hospital in sub-Saharan Africa: a 10-year review
Mary O. Ugalahi, Obioma C. Uchendu, and Linda O. Ugalahi
Mary O. Ugalahi, Department of Ophthalmology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Ibadan, Nigeria; Department of Ophthalmology, College of Medicine, University of Ibadan and University College Hospital, 200212 Ibadan, Ibadan, Nigeria;


To determine the preoperative visual acuity of cataract patients over a 10-year period in a tertiary facility as a means of auditing the cataract surgical services.


A retrospective study of patients with age-related cataracts who had cataract surgery performed between January 2007 and December 2016 at the University College Hospital, Ibadan. Systematic random sampling and probability proportionate to size were used to recruit a representative sample. Information on sociodemographic characteristics, preoperative visual acuity, ocular and systemic comorbidities were retrieved and analysed.


Of the 499 patients studied, males were 268 (53.7%) and their mean age was 67.69 (±9.51) years. The predominant visual acuity was hand motion 184 (36.9%) and yearly mean preoperative visual acuity was in the range of 0.0037–0.04 decimal.


The mean preoperative visual acuity of patients in this facility did not change over the 10-year study period. Mean value of preoperative visual acuity remained within the range of blindness and did not improve over the decade. This could either be a reflection of visual impairment at which our patients seek care or an indication of the range of visual acuities at which surgeons are willing to offer cataract surgery in our environment. This trend has negative implications on the burden of cataract blindness as it reflects poor coverage of surgery for other levels of visual impairment due to cataract.

Training of ophthalmoligists in ECSA sub-Saharan region

Interesting survey of sub-saharan ECSA training institutions was publushed by the London School of Hygiene and Tropical Medicine… Trabeculectomy remains difficult to master during ophthalmology resudency in Sub-Saharan Africa (ECSA Region). The majority master MSICS cataract surgeries. Phaco numbers remains close to zero, as it is mainly irrelevant skill for the majority of areas in the region: expensive, barely better as MSICS.

Wellcome Open Res. 2019 Nov 27;4:187. doi: 10.12688/wellcomeopenres.15580.1. eCollection 2019.
Survey of ophthalmologists-in-training in Eastern, Central and Southern Africa: A regional focus on ophthalmic surgical education.

Dean W1,2, Gichuhi S3, Buchan J1, Matende I4, Graham R5, Kim M6, Arunga S1, Makupa W7, Cook C2, Visser L8, Burton M1,9.
Author information:
1. International Centre for Eye Health (ICEH), Clinical Research Department Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E7HT, UK.
2. Department of Ophthalmology, University of Cape Town, Cape Town, South Africa.
3. Department of Ophthalmology, University of Nairobi, Nairobi, Kenya.
4. College of Ophthalmology of Eastern Central & Southern Africa, Nairobi, Kenya.
5. International Agency for the Prevention of Blindness, Durban, South Africa.
6. Tropical Epidemiology Group, Faculty of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
7. Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
8. Department of Ophthalmology, University of KwaZulu-Natal, Durban, South Africa.
9. Moorfields Eye Hospital NHS Foundation Trust, London, UK.


Background: There are 2.7 ophthalmologists per million population in sub-Saharan Africa, and a need to train more. We sought to analyse current surgical training practice and experience of ophthalmologists to inform planning of training in Eastern, Central and Southern Africa. Methods: This was a cross-sectional survey. Potential participants included all current trainee and recent graduate ophthalmologists in the Eastern, Central and Southern African region. A link to a web-based questionnaire was sent to all heads of eye departments and training programme directors of ophthalmology training institutions in Eastern, Central and Southern Africa, who forwarded to all their trainees and recent graduates. Main outcome measures were quantitative and qualitative survey responses. Results: Responses were obtained from 124 (52%) trainees in the region. Overall level of satisfaction with ophthalmology training programmes was rated as ‘somewhat satisfied’ or ‘very satisfied’ by 72%. Most frequent intended career choice was general ophthalmology, with >75% planning to work in their home country post-graduation. A quarter stated a desire to mainly work in private practice. Only 28% of junior (first and second year) trainees felt surgically confident in manual small incision cataract surgery (SICS); this increased to 84% among senior trainees and recent graduates. The median number of cataract surgeries performed by junior trainees was zero. 57% of senior trainees were confident in performing an anterior vitrectomy. Only 29% of senior trainees and 64% of recent graduates were confident in trabeculectomy. The mean number of cataract procedures performed by senior trainees was 84 SICS (median 58) and 101 phacoemulsification (median 0). Conclusion: Satisfaction with post-graduate ophthalmology training in the region was fair. Most junior trainees experience limited cataract surgical training in the first two years. Focused efforts on certain aspects of surgical education should be made to ensure adequate opportunities are offered earlier on in ophthalmology training.