Micro, Nano, Pico, Mono, Bi, or Triaxial Incision Cataract Surgery: What Do We Have to Do?

Big was beautiful in the past. In cataract surgery, however, smaller is the trend. This month's cover focus is dedicated to small, smaller, and smallest incisions.

It would seem that everybody has adopted this concept of microincision cataract surgery (MICS). But, the reality is that the majority of cataract surgeons still operate through a 3.2- to 2.6-mm incision. Are they (and possibly you) doing something wrong? Not necessarily; every surgeon must determine what is best for his patients. During postoperative visits, we examine the operated eyes and get feedback from our patients. If they are happy with the results, we are not too eager to change our surgical strategy. But is it time to reconsider our surgical technique and incision size?

Surgically induced astigmatism is certainly an important factor in reducing incision size, which can contribute to providing the best refractive outcome for the patient. The smaller the change incurred in the patient's cornea, the better the result should be—if the cornea is indeed spherical and requires no change to begin with. Of course, we should always try to minimize the traumatic impact of our surgical manipulations to the eye. Unfortunately, smaller incisions may not absolutely mean less trauma.

The incidence of complications should not increase as the incision size decreases. In recent years, companies have significantly improved the performance of their phaco equipment. It must be said that various phaco machine manufacturers and even some surgeons seem to claim the same thing: they all make or use the best machine. Today's phaco machines, however, do boast superior ultrasound delivery and/or better properties of fluid dynamics so that surgeons may reduce irrigation flow, imperatively with reduced incision size.

But, similar to judging a new car, you have to use the phaco machine yourself to determine whether it is a suitable vehicle for your own use. Luckily, all phaco machines on the market have improved a lot.

By far, the most important product that determines the patient's visual outcome, however, is the IOL. Its optical properties, position stability, biocompatibility, and long-term behavior are more important than the incision size alone. My personal recommendation would therefore be to select the IOL first and then choose the appropriate incision size for that particular IOL. New microincision IOLs are introduced frequently. It might be wise to be cautious and wait for long-term results before trying them for yourself. In every evaluation of a promising new IOL design, I include a prospective 2-year study for stability and posterior capsule opacification.

I certainly expect that high-quality IOLs and better injection systems for smaller incision surgery will be developed in the not-too-far future. You will certainly be updated in the future issues of Cataract and Refractive Surgery Today Europe!