SICS STEPS

Pande Made Gustiana

Divisi Katarak dan Bedah Refraktif

Rumah Sakit Mata Bali Mandara
 OUTLINE
• History of SICS
• Prepping & Draping
• Incision
• Capsular opening
• Hydrodissection
• Lens deliver
• Cortex removal
• Iol insertion
• Wound closure
 History of SICS

• Small Incision Cataract Surgery (SICS) introduced in early eighties in an

attempt to provide better wound healing with less surgically induced
astigmatism.
• Richard Kratz, in 1983 was the first surgeon to move the cataract incision
from the limbus to the sclera thereby increasing the surfaces of apposed
wound to produce enhanced wound healing and less astigmatism.
• Girard and Hoffman in 1984 were the pioneer to call this posterior
incision as scleral tunnel incision
 Prepping & Draping

• Pantocain/ local anesthethic drops is instilled into the eye

• Disinfect the skin of the lids and around the eye is performed with 10 % Betadine.
• Betadine drops into the conjunctival sac.
 Prepping & Draping

• 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

• The opening of the conjunctival flap in Manual SICS is done with

- forceps (Colibri/Pierce Hoskin) in the non-dominant hand and conjunctival
scissors in the dominant hand
• The flap is based toward the fornix.
• Initiation of the conjunctival flap is done at 10 clock hour.
• The conjunctiva has to be grasped just short of the limbus with forceps and a firm
vertical traction exerted to create a conjunctival fold
Fig. 1 Illustrating vertical traction causing
conjunctival fold away from the sclera

Fig. 2 Conjunctival/tenon opening with

exposure of underlying sclera
• Once the initial cut has been inflicted, the dissection of the conjunctiva and
tenons can be done separately. Alternatively, sub-tenon plane of dissection
can be directly sought.
• Blunt dissection of the conjunctiva is carried by initially inserting the blades
(closed) beneath the tenon capsule.
• The tip has to be directed toward the limbus and blades opened to
separate the tenons from the underlying sclera
• Undue posterior dissection has to be avoided. The conjunctiva is then cut
at the limbus flush with the cornea.
• During this step, the forceps should exert proper conjunctival/tenons
traction to lift it away from the cornea and the blades of the scissors
should be tangential to the cornea surface
Figs. Diagrams illustrating the position
and direction of conjunctival scissors
• An ideal conjunctival peritomy would thus expose the blue limbal zone without
overhanging conjunctival epithelium.
• A proper blunt dissection would have ensured that there is bare sclera at the
bed without any islets of tenons
• Presence of tenons may cause
• irregular incision of variable depth along its extent.
• prevents smooth movement of the tunnel blade, which predisposes
to septae within the tunnel.
• incorrect depth assessment while tunnelling.
 Cautery

The purposes of using cautery before initiating a scleral incision:

• Allow proper visualization of the instrument during tunnel creation which otherwise
gets obscured by blood.
• Prevent/minimize bleed into the anterior chamber intra- and postoperatively and
sub-conjunctival hemorrhage postoperatively.
• Wet-field bipolar cautery allows lateral distribution of heat over the scleral surface
compared to unipolar/thermal ball point cautery and hence it is preferred than the
latter.
 Scleral Incision

The essential elements of a self-sealing cataract incison in Manual SICS

are:
• External sclera incision – constructed by the blade/surgical knife
• Sclero corneal tunnel – constructed by tunnel blade/crescent knife
• Internal corneal incision – created by keratome
Fig. 1
illustrating perpendicular position of the
blade while making incision

Fig. 2 Non-sagging and

closely apposed incision
Fig. 10 Blade held at an angle to the sclera

Fig. 11 An Angled wound resulting in wound

gape following surgical manuvering
The characteristics of the external scleral incision include:
1. Size
2. Shape
3. Location
4. Depth

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.

(b) Tilt of the blade greater than the

contour of the globe causing
premature entry and tilt of the blade
lesser than the contour of the globe
causing buttonhole
Keratotomy :
• Entry into anterior chamber is made with a bevel down keratome by using the
dimple- down technique.
• This third plane gives the tunnel a secure and valved effect.
• In the dimple-down technique, care is taken to enter the keratome so
that the tip reaches the anterior extent of the sclerocorneal tunnel.
• This is done by pivoting the blade rather than directly entering the tunnel.
• Direct entry of the sharp tip into the tunnel can cause inadvertent premature
entry into the floor of the sclerocorneal tunnel.
• Once the tip reaches the anterior extent of the tunnel, the heel of the keratome is
lifted up to make the entry into AC as perpendicular
as possible. This ensures the creation of a third plane.
• The globe has to firm before entry lest it may lead to lamellar entry or Descemet’s
detachment. This is achieved by filling the AC with viscoelastic substance through
the side port.
Extension
• Once entry into the AC is achieved, the keratome is kept parallel to the plane of the
iris and tunnel extended with forward cutting movement on either sides (in contrast
to backward cutting movement with crescent blade).
• The extension of the internal lip is done from limbus to limbus.
• The inner lip thus created should be concentric to the tunnel or straighter
• The idea is to have adequate corneal floor to maintain the integrity of
the sutureless tunnel.
(a) Pivoting of the keratome to reach the anterior extent of the
tunnel.
(b) Dimpling down the tip of the keratome to achieve the third
plane
(a) Internal view of the keratome during extension.
(b) Ideal three-planed tunnel
Ideal Tunnel
• Location :1.5–2 mm from anterior border of limbus
• Depth : between 1/2 and 3/4 thickness of the sclera
• 1.5 mm internal corneal lip
• The wound construction in small incision cataract surgery in the form of a
sclerocorneal tunnel should aim to achieve a self-sealed, astigmatically neutral
wound.
• A guarded 0.3 mm diamond or steel knife is the best for making the external
groove.
• Alternatively a knife with 11 number blade can be used.
Depth of Incision
• The optimal depth for the sclera flap incision is 0.3 mm, i.e., half to
one third of the scleral depth.
 Basic Principles of the Capsulotomy

• The opening should be large enough to accommodate the lens or lens

fragments without causing complications.
• It should be sufficiently stable to prevent anterior capsular tears from continuing
to the posterior capsule.
• It should ideally allow 360° of capsule, optic overlap
• Can opener capsulotomy comes from the multiple tears that allow stresses on the
capsule to be shared among the multiple points of weakness.
• CCC has a single tear, which allows only a single point where forces may be
distributed.
Continuous Curvilinear Capsulorrhexis (CCC)
- In the 1980s, Gimbel and Neuhann both independently developed
the CCC
Description of Technique
- Using either a cystotome needle or capsulorrhexis forceps, a puncture is
made in the central anterior capsule
- This initial puncture is then directed peripherally either in a clockwise or
counterclockwise fashion depending on surgeon preference.
- Either the tip of the cystotome or a forceps is used to fold over the capsular
flap akin to a folded napkin
Fig. 1 Initiation of CCC with
central puncture

Fig. 2 Turning over the flap

Fig. 3 Leading the tear around

Fig. 4 The completed

CCC with PCIOL
Hydrodissection Technique :
• Prior to beginning hydrodissection, the posterior lip of the main
incision is compressed so as to remove a small amount of viscoelastic
from the eye to create a space for the fluid wave to make its way in
the eye while
performing hydrodissection.
• Failure to do so may often lead to overinflation of the eye with fluid
and may often eventually lead to increased pressure and a PCR
Fig. 1 The hydrodissection cannula is
placed beneath the margin of anterior
capsule and fluid is injected. Initiation
of the fluid wave is seen

Fig. 2 Fluid wave progresses and reach

the posterior pole of the nucleus
Fig. 3 Fluid wave advances
further

Fig. 4 Fluid wave is about to

cross the posterior plane of the
lens and reach the equator
Hydrodelineation
• Hydrodissection is CI in posterior polar cataracts as they are a/w
weakness of the posterior capsule and hydrodelineation is
recommended to preserve an epinuclear cushion to work on.
• Brunescent cataracts require specific precaution because the
nucleus occupies the entire crystalline lens.
• Multiple-quadrant hydrodissection with minimal amount of fluid
should be done in such cases
Hydrodelineation is performed in a
case of posterior polar cataract and
the “golden ring” is visible
Nucleus delivery involves two steps:
• Prolapsing nucleus into anterior chamber
• Nucleus delivery through scleral tunnel
• Since nucleus delivery necessitates a lot of manipulation within the
anterior chamber, copious amounts of ophthalmic viscosurgical devices
(OVD) should be used to protect the corneal endothelium.
Prolapsed lateral pole of the nucleus
Nucleus prolapse Bimanual prolapse of the nucleus
with the Sinskey hook
• Once the nucleus is luxated into AC, the tip of the Sheet’s glide is gently
introduced through the section under the upper pole of the nucleus up
to 1/3 of the way.

• With an iris spatula/McPherson forceps the tunnel is depressed by

pressing on the glide. The nucleus gets engaged in the tunnel.

• The bottle height is increased to 70 mm, thereby increasing the

hydrostatic pressure in the AC.
• Further continued pressure on the glide will cause the nucleus to
shave off the epinucleus and mould itself into the tunnel till it is finally
expelled out. This procedure is repeated again to expel the epinucleus.
• Caution : The glide should be inserted under the nucleus and is
pushed towards 6 o’clock and not posteriorly to prevent PC rent.
IOL Implantation
Technique of IOL Placement in bag
• The IOL placement can be done under viscoelastics, under continuous
irrigation, or under an air bubble
• Comprises two steps

Technique of Leading Haptic Insertion

• For insertion of a rigid IOL, hold the optic and trailing haptic with McPherson and
place the IOL into the eye, directing the leading haptic towards inside the capsular
bag.
• To ensure that the optic is seated into the bag, partially release the grip over the
optic and allow clockwise rotation of the optic in to the bag.
• Once the optic and leading haptic are in the bag, the trailing haptic can be inserted
into the bag in two ways
Technique of Trailing Haptic Insertion Using Forceps
• Inject additional viscoelastic to inflate the capsular bag and anterior chamber.
• Hold the trailing haptic near the tip and move it to the 3 o’ clock position by folding
the haptic over the optic.
• The haptic is depressed and released below the capsular margin
• This is accomplished by the surgeon abducting the arm and pronating the forearm
more while placing the haptic in to the bag.
• This maneuver is more suitable for a multipiece IOL.
IOL placement using forceps
IOL placement using forceps
Using Sinskey Hook
• This step can be done through the main tunnel or through the sideport. IOLs
with a dialing hole can easily be dialed in to the bag by placing sinskey hook in
the dialing hole and by rotating the IOL with a downward movement for 2–3
clock hours preferably from 3 o’clock to 6 o’clock hour .
• IOLs without a dialing hole can also be dialed using sinskey hook. Here the sinskey
hook is positioned at optic-haptic junction and rotated to 3 o’clock hour over the
iris and then rotated with a downward movement aiming the optic-haptic junction
to go under rhexis which will eventually take the whole haptic inside.

• Here the surgeon’s forearm position has to change from pronation to a

little supination.

• 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.
THANK
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