Converting from Phacoemulsification to Manual Small-Incision Cataract Surgery

  • Sudeep Das
  • Mathew Kurian
  • Nikhil Negalur
  • Purnima Raman Srivatsa


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.


Anterior Chamber Cystoid Macular Edema Triamcinolone Acetonide Triamcinolone Acetonide Anterior Vitrectomy 
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Financial Interests

None of the authors have any financial interests in any company or product mentioned in the text

Supplementary material

Video 19.1

(MPG 1860760 kb)


  1. 1.
    Trinavarat A, Neerucha V. Visual outcome after cataract surgery complicated by posterior capsule rupture. J Med Assoc Thai. 2012;95 Suppl 4:S30–5.PubMedGoogle Scholar
  2. 2.
    Hashmani S, Haider I, Khan MA. Phacoemulsification: results and complications during the learning curve. Pak J Ophthalmol. 1997;13(2):32–6.Google Scholar
  3. 3.
    Blumenthal M, Moisseier J. Anterior chamber maintainer for ECCE & IOL implantation. J Cataract Refractive Surg. 1987;13(2):204.CrossRefGoogle Scholar
  4. 4.
    Ruit S, Tabin GC, et al. Low cost high volume ECCE with posterior chamber intraocular lens in Nepal. Ophthalmology. 1999;106(10):1887–92.CrossRefPubMedGoogle Scholar
  5. 5.
    Bobrow JC. Visual outcomes after anterior vitrectomy: comparison of ECCE & Phacoemulsification. Trans Am Ophthalmol Soc. 1999;97:281–95.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Gimbel HV. Posterior capsule tears using phacoemulsification: causes, prevention & management. Eur J Implant Refractive Surg. 1990;2(1):63–9.CrossRefGoogle Scholar
  7. 7.
    Turnbull CS. The hydrochlorate of cocaine, a judicious opinion of its merits. Med Surg Rep. 1884;29:628–9.Google Scholar
  8. 8.
    Swan KC. New drugs and techniques for ocular anaesthesia. Trans Am Acad Ophthalmol Otolaryngol. 1956;60(3):368–75.PubMedGoogle Scholar
  9. 9.
    Singer JA. Frown incision for minimizing induced astigmatism after small incision cataract surgery with rigid optic intraocular lens implantation. J Cataract Refract Surg. 1991;17(Suppl):677–88.CrossRefPubMedGoogle Scholar
  10. 10.
    Pallin SL. Chevron incision for cataract surgery. J Cataract Refract Surg. 1990;16(6):779–81.CrossRefPubMedGoogle Scholar
  11. 11.
    Gokhale NS. Viscoexpression technique in manual small incision cataract surgery. Indian J Ophthalmol. 2009;57:39–40.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Michelson MA. Use of a sheet’s glide as a pseudoposterior capsule in phacoemulsification complicated by posterior capsule rupture. Eur J Implant Refractive Surg. 1993;15(1):70–2.CrossRefGoogle Scholar
  13. 13.
    Couch SM, Bakri SJ. Use of triamcinolone during vitrectomy surgery to visualize membranes and vitreous. Clin Ophthalmol. 2008;2(4):891–6.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Wagoner MD, Cox TA, et al. IOL implantation in absence of capsular support: a report by the AAO. Ophthalmology. 2003;110(4):840–59.CrossRefPubMedGoogle Scholar
  15. 15.
    Tewari A, Gaurav KS. Cataract Complications: The retinal perspective. Rev Ophthalmol. 2006;2(8). (Online Digital Journal).
  16. 16.
    Balent A, Civerchia LL, Parivash M. Visual outcome of cataract extraction and lens implantation complicated by vitreous loss. J Cataract Refractive Surg. 1988;14(2):158–60.CrossRefGoogle Scholar

Copyright information

© Springer India 2017

Authors and Affiliations

  • Sudeep Das
    • 1
  • Mathew Kurian
    • 1
  • Nikhil Negalur
    • 1
  • Purnima Raman Srivatsa
    • 1
  1. 1.Cataract and Refractive SurgeryNarayana NethralayaBangaloreIndia

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