Ophthalmologists seem to love acronyms: our literature, discussions, and patient charts are filled with them. Each subspecialty even has its own jargon. As cataract surgeons, we know ICCE, ECCE, IOL, PCO, RLE, etc., and more recently MICS (microincision cataract surgery). While I enjoy using acronyms as much as anyone else, and have sometimes created entire sentences without a real word, I’m not quite sure how necessary this one is. Even the continued debate over which microincisional technique is best seems to be unnecessary.
The improvements in cataract surgery are truly remarkable. If we think about the current technology and how far we have advanced since the days of intracapsular surgery and closed-loop anterior chamber lenses, it really is incredible. Cataract surgery has always been refractive surgery, but now we are acknowledging this fact because we can more accurately and predictably achieve excellent target outcomes. The incision size has been reduced from greater than 10 mm to 6 mm with phacoemulsification and rigid lenses to 3 mm with foldable lenses to less than 2 mm now. At first we called this small incision cataract surgery, now that we’re smaller than a small incision we’ve renamed it microincision. I never did see the acronym SICS; MICS certainly sounds a lot better. But do we really need a new acronym? I think not. What happens when we are performing cataract extraction through a sub-1 mm incision, will this be submicroincision (SMICS), mini-microincision (M2ICS), or maybe nanoincision (NICS) surgery? Basically, we’re operating through smaller and smaller incisions, but do we really need to invent new names for each variation of a procedure or is this more of a sound bite for patients to demonstrate that we are offering them the latest and greatest surgery?
On a more serious note, let’s take a closer look at the actual procedures that have been compared for the past few years: coaxial vs. bimanual surgery. Originally, MICS referred specifically to bimanual surgery. At that time, the smallest coaxial phaco needles required at least a 2.8 mm incision, whereas the bimanual procedure enabled phacoemulsification through a much smaller wound (1.5 mm) since the I/A and ultrasound components were split between two separate handpieces. However, two incisions are required and one needs to be enlarged or more commonly a new one created for lens insertion; therefore, the total wound length is actually > 4 mm, which is not a microincision any more. In addition to a steep learning curve, the other main drawback of the bimanual technique is wound leakage, which is inevitable because of the rigid metal instruments without silicone sleeves to seal the wound.
The true benefits of the bimanual technique may be for improved access since the phaco handpiece can be used with either hand (analogous to bimanual I/A), soft nuclei especially refractive lens exchange, and special situations such as weak zonules or IFIS. Although some surgeons touted the better safety and fluidics of such a bimanual system, modern safety and fluidics of coaxial systems have been as good or better. Now that a coaxial instrument is available to fit through a 1.8 mm incision, some bimanual advocates are rediscovering the advantages of coaxial surgery.
The concept that smaller is better for cataract surgery has not really been proven for MICS. At a certain point the trade-off between safety and efficiency shifts in the opposite direction and becomes more of a hindrance than a benefit. In addition, as long as larger wounds are necessary for IOL insertion, much of the advantage of bimanual surgery is lost. It is not surprising that this technique has been poorly embraced by most cataract surgeons. When we have lenses that are implantable through our smallest incisions, then we may see the true value of a bimanual method. For now, I will continue to use coaxial phacoemulsification.
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