Irecently had the pleasure of moderating the second MICS Masters live surgery event hosted by the Belgian Society of Cataract and Refractive Surgery. It was at the first MICS Masters symposium in January 2008 that I became convinced of the value of microincision cataract surgery (MICS). Observing cataract removal through ultra small incisions made my own technique of conventional phacoemulsification surgery seem a bit medieval.
I made a very rapid transition to coaxial MICS. To be honest, there really was not much of a transition, as the only significant changes were the use of a new instrument to perform capsulorrhexis and learning to deal with the more modern fluidics and improved efficiency of a new-generation phacoemulsification platform.
What I immediately noticed is that cataract surgery became fun again, and I was thrilled with the sports–car-like performance of our new phacoemulsification machine with dual-linear controls, hazardfree stable chambers, and pristine appearance of the eye at the conclusion of surgery. As Jean-Luc Febbraro, MD, discusses in his article in this issue, coaxial MICS is essentially the same technique as standard phacoemulsification, and thus there is not much of a learning curve; however, coaxial MICS provides additional benefits, including more controlled surgery with better outcomes and more rapid visual recovery.
The benefits of a very stable anterior chamber and more controlled surgery are especially important for treating patients with intraoperative floppy iris syndrome and in cases of zonular loss. Both situations are discussed at length in this issue’s cover focus on MICS techniques. To further increase chamber stability, Guy Sallet, MD, relies on a second infusion bottle to minimize posterior segment changes and reduce posterior vitreous detachment and retinal tears. This strategy may be especially useful in patients at risk for such complications.
Jorge L. Alió, MD, PhD, overviews bimanual MICS, a technique that undoubtedly requires a longer learning curve than coaxial MICS, and raises the issue of appropriate implants to complement small-incision surgery. There are now many IOLs that can be inserted through 1.8-mm incisions, and some of these are also able to provide the benefits of multifocality and toricity. Jérôme C. Vryghem, MD, discusses one such lens, the trifocal FineVision lens (PhysIOL, Liége, Belgium). I have had the pleasure of using this lens to provide patients with intermediate (yes it does work) as well as distance and near vision. In due course, this lens will be available as a multifocal toric. This is probably as good as it gets in 2011—and all through a microincision.
The naysayers to MICS used to argue that there was no point in making smaller incisions, as they only had to be enlarged to accommodate IOL implantation. This is no longer the case, and I suppose the argument now should be turned on its head: As very sophisticated implants can be inserted through microincisions, why continue to make larger incisions?
So between the intraoperative benefits of MICS, the ability to improve refractive and visual outcomes, and the increased availability of microincision lenses, why aren’t more surgeons using MICS? Perhaps many are waiting for laser cataract surgery, which may well open a new door of possibilities. Yes I hear what you are thinking, “Femtoseond lasers are unaffordable, and the advantages are not substantial.” But it is not what it offers as a substitute but what opportunities the technology will provide. Laser cataract surgery could very well heighten patient satisfaction and, in turn, our goals for predictable cataract surgery. Good substance for a future editorial!
As usual, we encourage an open line of communication with our readers, and it will be a pleasure to learn more about your use of MICS and whatever pearls of wisdom you can offer your colleagues who are getting ready to make the transition. In the meantime, let this cover series be your guide to the various techniques used for MICS. Each article is accompanied by a video on our sister site, http://eyetube.net. New in this issue, you can now use a QR code to directly link to the video.