Sics Steps: Divisi Katarak Dan Bedah Refraktif Rumah Sakit Mata Bali Mandara
Sics Steps: Divisi Katarak Dan Bedah Refraktif Rumah Sakit Mata Bali Mandara
Sics Steps: Divisi Katarak Dan Bedah Refraktif Rumah Sakit Mata Bali Mandara
• Sterile towel placed over head and then applied the drape.
• Here, care has to be taken to get all the eyelashes under the plastic drape so that they do
not come into the surgical field.
• While applying the eye speculum, one can further ensure that the lashes are tucked back
under the lids covered by the drape.
First step of Manual SICS
• A bridle suture is applied. It gives the surgeon control over moving the otherwise
anesthetized and immobilized eyeball
• It also lets one turn the globe in particular directions while performing specific
steps
• If the surgery is planned under topical anesthesia, a local infiltration with lidocaine
around the area (muscle insertion) where the bridle suture is planned is preferred
because applying a bridle suture can sometimes be painful .
Technique of Applying a Bridle Suture
• For adequate exposure of the superior rectus muscle, the globe can be held by a
toothed forceps at the limbus diagonally opposite to the muscle
• The muscle insertion is identified according to its distance from limbus (either superior
7.7 mm or temporal 6.9 mm), and the muscle is grasped just beyond the insertion with
the superior rectus holding forceps.
Technique of Applying a Bridle Suture
• Superior rectus holding forceps has a double curve at the end. When the proximal bent is
placed at the limbus, the distal bent at the tip will be at 7.7 mm from the limbus to catch
muscle with its single large tooth at the tip
• The curved needle (with cutting edge) threaded with cotton or 6–0 silk suture is passed
under the area held by the forceps to include the muscle also in the bite
• The thread can then be held taut and fixed to the drape using an artery forceps
Superior rectus bridle suture (a). Superior conjunctiva exposed. (b).
Superior rectus muscle grasped.
(c) Suture passed under the muscle (d). Globe steadied by pulling and clamping the suture
Lateral rectus bridle suture (a). Temporal conjunctiva exposed. (b). Lateral
rectus muscle grasped.
(c.) Suture passed under the muscle. (d). Globe steadied by pulling and
clamping the suture
Conjunctival Peritomy
Size
• The size of the incision on the sclera is titrated according to the density of the nucleus to be extracted.
• Average equatorial diameter of an adult lens (8.8–9.2) as 9 mm & sclera extensibility of 0.5–1 mm, so
nucleus of any size can be promptly delivered through the external incision.
• Harder cataracts have lesser epinucleus and are less yielding.
• Hence the size has to be appropriate lest there will corneal endothelial damage and/or nuclear
fracture while delivery.
Shape
The concept of arc length and chord length has to understand to know the
effect of various shaped incisions
• Arc length is measured along the line of incision.
• Chord length is measured from point of initiation to the point of
ending of the incision (end to end).
Various incision configuration which are used are as follows:
• Smile incision incision is made parallel to limbus the inferior edge of the incision may fall
back, which flattens the cornea in this meridian.
• If the incision is made at 12 o’ clock, this incision flattens the vertical meridian of the cornea,
causing against the rule astigmatism.
• Straight incision Incision is not parallel to limbus there are no chances of the inferior edge
falling back.
• Whatever astigmatism is by the straight incision is because of the instability of the central
portion of the wound, which is much less than the smile incision.
Smile incision Straight incision
Although both these incisions open the wound better during nucleus delivery, they induce
more astigmatism.
Frown/chevron/inverted bat wing:
• The common feature shared by these incisions is that their chord length is less
than the arc length.
• Lesser astigmatism is produced because the edges of this incision are further away
from the cornea. Therefore, this incision induces the least amount of astigmatism.
Astigmatically Neutral Funnel
• The concept of astigmatic funnel arose from two mathematical relationships:
- corneal astigmatism is directly proportional to the cube of the length of the
incision
- corneal astigmatism is inversely related to the distance from the limbus.
Chevron Inverted batwing
Frown incision incision
incision
Location
• Usually the convex part of the frown incision is along the posterior limbal line.
• This corresponds to about 1.5 mm from conjunctival insertion.
• Ideal incision depth should be half to three fourth of the scleral thickness.
• It should be uniformly deep along its length.
- <50 % Thin roof/buttonhole during tunnelling
- 50–75 % Optimal
- >75 % Deeper plane/thin floor/premature entry
- 100 % Scleral disinsertion/ciliary prolapse
Sclerocorneal Tunnel Construction Steps
1. Initiation – Finding the right plane
2. Propagation – Maintaining the achieved right plane and widening the
tunnel to desired dimension
3. Keratotomy – Entry into the AC to create a third plane for the valve effect
4. Extension – Extending the inner corneal lip to the desired dimension
Initiation :
• Once an incision is made, the incision is swept with the tip of the crescent blade
(bevel up). This is done so that the incision along its entire length is smooth,
nonragged, and of uniform depth.
• In the subsequent sweeps, the heel of the blade is slowly lowered such that it
rests on the scleral surface.
• If the heal of the blade is
- very low, there is a possibility of superficial plane/buttonholing
- very high, then there is a possibility of deeper plane/premature entry
• The heel of the blade should be just above the scleral surface to get the right plane
(a, b) Heel of the blade very low, causing subsequent buttonholing
(c, d) Heel of the blade very high, causing subsequent deep plane and
premature entry.
(e, f) Heel of the blade is just above the sclera surface to get the correct
plane
Ideally
• the width of the tunnel is about 3–3.5 mm and
• length of the tunnel at its
• anterior (corneal) extent is 7–8 mm and
• posterior (scleral) extent is 6–7 mm .
(a) Diagram
illustrating maintenance of the tunnel
blade along the contour of the globe.
• Care should be taken to inflate the bag with viscoelastics so that the
sinskey hook will not tear the posterior capsule.
IOL placement using sinskey book
Confirmatory Signs
• The appearance of stretch lines in the center of the posterior capsule confirms
that the capsular bag is maximally distended due to the correct placement of
the optics and haptics
• In cases where the haptic is inadvertently in the sulcus, no stretch line will be
seen.
• Another method of determining whether the haptic is in the bag is to visualize
the shiny appearance of the anterior capsular rim over the haptic or to use a
blunt instrument to push on the IOL to ensure that it is under the capsule.
Confirmatory signs of IOL in capsular bag
Viscoelastics Removal
• needs to be removed thoroughly before completing the surgery to avoid
postop complications such as elevated IOP and capsular bag distension
syndrome
Technique and Pearls
• Initially the viscoelastic under the IOL is removed by placing simcoe
cannula beneath the IOL with the aspirating port facing up
• The viscoelastic is displaced simply by the irrigation and often no active
aspiration is needed unless dispersive viscoelastics are used.
• This is followed by aspiration of the viscoelastics in the AC.
• It is accomplished by irrigating with simcoe cannula in the center of the
chamber then aspirating starting from inferior part of ACand then all
around with the aspirating port facing up
Checking the Wound Integrity
• Wound leaking is checked at the end of surgery after forming AC with BSS and
hydrating the sideport wound.
Technique:
• Gently tap on the dome of the cornea or at the limbus diametrically
opposite to the wound with the hydro-cannula.
• Check the tension status of the AC and wound stability.
• A well-formed AC gives a firm feeling of resistance and does not give way on
applying pressure.
• The surgeon should look for any leaks from the wound sites.
• If folds appear on the Descemet’s layer on tapping, it implies that AC is not formed
adequately
Wound closure
Closing the Sclerocorneal Tunnel
• The beauty of the main sclerocorneal tunnel (SC tunnel) lies in its self-sealing
nature.
• A good wound construction is the main prerequisite to ensure a good closure of
the wound.
• Just forming the AC with BSS or RL creates a valve effect which opposes the
posterior corneal lip to the anterior part of the tunnel, sealing the wound shut.
• The normal IOP should be enough to close the inner lip of the corneal valve
and keep the tunnel closed.
• At the end of the surgery, AC can be formed by either via the main tunnel or
through the side port(s) or anterior chamber maintainer (if attached).
(a) Wrong way to place suture. (b) Sagging of wound due to
improper depth. (c) Right way of giving suture
Side-Port Closure
• by hydrating the surrounding corneal stroma.
Technique:
• Inject small amount of BSS through hydro-cannula in the stroma gently at the
side port.
• The edema will be visible as a whitening of the stroma which resolves by itself in
few hours
• The increased corneal thickness closes the wound. Complication
• point the cannula away from DM by keeping the tip of the cannula at the middle,
directing towards limbus (not towards AC)
• Avoid injecting with too much force. Otherwise, this can accidentally
lead to a Descemet’s detachment.
Conjunctiva Closure
• almost always done with wet-field cautery.
Technique:
• The cut ends of the peritomy flap are brought together and held in place with
forceps-designed cautery. The ends are then cauterized together.
• Good closure is very important for temporal sclerocorneal sections where
the wound is otherwise exposed with higher infection risks.
Sutures:
• Conjunctival shortening for excessive cautery or in glaucoma combined
surgeries.
• Simple interrupted sutures with 8-0 Vicryl are commonly used.
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