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MISTAKES TO AVOID IN SICS : A STEP-WISE APPROACH

Dr CharuduttKalamkar, Dr Rohit Rao
Shri Ganesh Vinayak Eye Hospital, Raipur

Case Selection: Avoid SICS in eyes with

Thin Sclera; Post Scleritis; History of Multiple Surgeries
Glaucoma; to preserve superior conjunctiva as scarring may occur following surgery
Microphthalmic Eyes
Narrow Palpebral Apertures
Pediatric Eyes

In Tunnel construction- avoid

Poor Globe Stabilization; due to improper superior rectus suture or due to poor holding with forcep.
Poor Visualisation; due to bleeding
Poor Tissue Dissection; not exposing sclera due to incomplete tenon dissection or improper tissue plane identification
Improper Crescent Blade Placement-superficial/deep and improper movement of blade
Side Pocket Construction; Poor or absence

In Side Port construction - avoid

Improper Globe Stabilization- holding just conjunctiva or not holding exactly opposite
Improperly Positioned Globe- not positioning in the primary gaze
Improper Starting Point-very anterior into the cornea/very posterior limbal/sclera
Very Small or Very Large Side Port
Improper Direction of Entry- going tangentially or superficially leading to difficulty in entering instruments, risk of capsule damage.

In Rhexis construction- avoid

Poor Capsular Visualisation-no staining/poor staining, capsular flap crumpling, air bubbles in AC.
Trying to do  Rhexis - in a shallow AC/improperly filled AC, undue pressure on the posterior lip, doing rhexis from main port instead of side port.
Failure to apply Physics of Rhexis- improper direction of pull, improper positioning of cystitome tip, applying more pressure than required
Inadequately sized Rhexis-small /very large, extension
Limiting to just cystitome, not using Forceps or improper utilisation

While doing Hydro Procedures- avoid

Improper positioning of cannula- below anterior Rhexis rim and failure to lift up capsule before injecting fluid. 
Doing inapt Hydrodissection-
Under-Hydrodissection- it may lead to difficult nucleus rotation and prolapsed
Over-Hydrodissection - especially in small rhexis- Dreadful combination for nucleus Drop(Capsular Block Syndrome).
Sulcus Hydration – may lead to pupil constriction
Using Improper Gauge Cannula:
Small gauge- may cause incomplete dissection
Large: risk of over hydro
Not tapping nucleus in between- to release posteriorly accumulated fluid.

While Keratome Entry- avoid

Entering too early, into the floor of the tunnel
Direction of entry parallel to tunnel: may lead to uni-planer tunnel, blade should be directed towards center of globe at an angle to the tunnel plane.
Extending the tunnel - with inside –out motion instead of the recommended outside-in
Trying to enter the AC - with soft globe or with Improperly stabilized globe
Using a blunt Keratome – it may lead to DMD

Nucleus Prolapse and Delivery- avoid

Hooking the nucleus vigorously without capsular visualisation and Trying to deliver the nucleus without properly engaging the nucleus.
Inadequate coating of endothelium and inadequate visco cushion between nucleus and posterior capsule
Inadequate Traction/counter-traction : Not depressing the lower lip/not pulling the superior rectus properly.
Improper tunnel size estimation- in correlation to nucleus size - over estimating the tunnel size.
Improper Rhexis size estimation - in correlation  to  nucleus size- over estimating the Rhexis size.

While doing CORTEX WASH - avoid

Repeated AC shallowing - trying to do total cortex wash from main port with out using side port/not using side port sufficiently.
Trying to aspirate - without proper visualisation or in small pupil- catching posterior capsule or Rhexis margin.
Defective Simcoe cannula-
partially blocked - less inflowing fluid causing AC shallowing
Sharp edged cannula -risk of PCR
using higher volume syringes (10 ml instead of 2/5 ml) to aspirate -may create higher vaccume disproportionate to fluidics,
Aspirating the cortex near equator- instead of pulling it centre and then aspirating.
Keeping Simcoe cannula
too anterior near the iris plane: catching iris repeatedly
too posterior - catching posterior capsule

While Implanting IOL- avoid

Under inflating bag with OVDs.
Not directing the leading haptic into the Bag
After inserting leading haptic, Not reforming AC and Capsular Bag with OVD, which would help in dialing trailing haptic and avoiding inadvertent sulcus placement.
Incorrect technique of dialing trailing haptic into bag: it has to be rotatory as well as posteriorly directed.
Inability to identify whether the IOL/haptic is in bag or sulcus; Inability to identify zonular dialysis, PCR while dialing or IOL insertion: Decentered /Tilted IOL gives clue to these.
 

 

Rohit RaoDr Rohit Rao, completed MBBS from JNMC Wardha Maharashtra in the year 2010. Done MS ophthalmology from JSS MEDICAL COLLEGE Mysore Karnataka in 2015. Underwent long-term fellowship in IOL and Anterior segment under the guidance of Dr Kalpana  Narendran at Aravind eye hospital Coimbatore in 2017.He underwent short term DCR fellowship from Shankara eye hospital Coimbatore under Dr Shruti Tara. Presently he is working as an Anterior Segment surgeon and oculoplasty consultant At Shri Ganesh Vinayak eye hospital, Raipur Chhattisgarh. He has quite a few National and International papers , videos and e-posters under his name. He has been very much involved in training new surgeons at Shri Ganesh Vinayak eye hospital Raipur Chhattisgarh.

Charudutt Dr. Charudutt Kalamkar did his MBBS and MS from AIIMS (N.DELHI). Apart from routine phacoemulsification surgery for cataract, he is incharge of squint and glaucoma units. He also has rich experience in oculoplasty. He is the director of Shri Ganesh Vinayak eye hospital, Raipur, Chhattisgarh. It is the largest NABH accredited eye hospital in Chhattisgarh hosting Phacoemulsification, SICS, and ICO Fellowships. He has multiple indexed publications and many presentation at national & international conferences.