I currently perform—in 99% of my surgical cases—microincisional cataract surgery (MICS). I have evolved my technique toward MICS for the following reasons: (1) I am able to control induced astigmatism following cataract surgery, (2) I have the same control with induced corneal aberrations, (3) the technique is safer and more stable compared with standard phacoemulsification, (4) MICS IOLs are readily available, and (5) my personal conviction is that MICS will improve my performance for the future evolution of cataract surgery. There is no doubt that cataract surgeons desire to create smaller incisions, and the recent push toward microcoaxial phacoemulsification clearly indicates this trend.

In my MICS surgical technique, incisions are placed 90º apart, where one incision always coincides with the positive meridian of the cornea. If a relaxing incision is performed, I make it at the positive meridian level, and the microincisions for cataract surgery are performed away from this incision. I perform each incision with a 1.2-mm or 1.5-mm external calibrated knife for 21- or 19-gauge MICS (0.7 mm), respectively. Internal incisions for each blade correspond to 1 mm and 1.4 mm for 21- or 19-gauge MICS, respectively.

MYDRIATICS
After the incisions are made, I follow with intraocular mydriatics. I do not dilate the pupil with topical mydriatics in any case. Instead, I use a topical tropicamide 10% and fenilefrine 10% combination with no preservatives, which is prepared at our pharmacy in a galenic preparation. A viscoelastic (Viscoat; Alcon Laboratories, Inc., Fort Worth, Texas) is added and later insufflated by methylcellulose 2% to push and adhere the viscoelastic to the corneal endothelium.

I perform the capsulorrhexis with the Alió MICS Capsulorrhexis Forceps (Katena Products, Inc., Denville, New Jersey), and then hydrodissect the cortex. I rotate the nucleus two to three times with the Alió Prechoppers (Katena Products, Inc.), and prechopping is performed. Prechopping is usually achieved in approximately 70% of the cases, however, it may not be achieved if the cataract is too hard. Even in these situations, the marks created by the choppers weaken enough of the nucleus to allow for easier evacuation by the following manoeuvres.

For 21-gauge MICS, I use the Duet (Microsurgical Technologies, Redmond, Washington) 0.7 mm, 45º phaco tip and the Alió irrigating stinger (Microsurgical Technologies) (Figure 1). For 19-gauge MICS, I use the irrigating stinger and the Infiniti System (Alcon Laboratories, Inc.) Kelman Tip, with OZil energy (Figure 2). The Infiniti settings I use are found in Table 1.

Usually, MICS is performed with up to 4% ultrasound power and fewer than 10 seconds of real phaco time. I do not change the instruments during surgery, because the irrigating stinger is multifunctional and assists the surgery from the beginning until the end. I do change hands and exchange instruments from one incision to the other, so as to clean the capsular bag extensively. I always place the irrigation instrument in a power position over the aspiration instrument, preserving the capsular bag—wide open toward the vitreous cavity—and elevating the fragments and cortex remains toward the aspiration. This avoids the risk of posterior capsular disruption.

Once I have eliminated the nucleus, I clean the epithelial cells of the anterior capsular remains. I insufflate the capsular bag with methylcellulose, and I insert an Acri.LISA (Acri.Tec AG, Hennigsdorf, Germany) or an Akreos (Bausch & Lomb, Rochester, New York) MICS IOL (Figure 3). For all of our cases, I prefer to use the 48S (5.5-mm optic), or the 36A aspheric (6-mm aspheric optic). For multifocals, I use the 36A Acri.LISA. I also use toric implants, and for cases with more than 3.00 D of astigmatism, I use the toric Acri.Tec IOL, marking the axis of the implantation at the slit-lamp prior to surgery. These lenses are available from 1.00 D power to 30.00 D. In the toric design, there is up to 15.00 D of toric add.

Once the lens is implanted, I evacuate the viscoelastic with low vacuum, and I hydrate the incisions with a 30-gauge cannula. The procedure is finished with an intraocular injection of 0.1 cc to 0.2 cc of cefuroxime and two drops of 50% diluted povidone iodine.

I only use coaxial phaco in extremely brunescent cataracts, which currently account for fewer than 1% of my practice.

Jorge L. Alió, MD, PhD, is Professor and Chairman of Opthalmology, at the Miguel Hernández University, in Alicante, Spain, and Medical Director of VISSUM Corp., in Spain. Professor Alió states that he is the owner of MICS as a registered name in Europe. He may be reached at +34 96 515 00 25; jlalio@vissum.com.