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Microincision Cataract Surgery

Abstract and Introduction Principles of MICS Bi-MICS Technique Continuous Curvilinear Capsulorhexis Hydrodissection Prechopping Phacoemulsification & Power Modulation Fluidics Co-MICS Technique MICS Intraocular Lenses MICS Results Conclusion Expert Commentary Five-year View Microincision Cataract Surgery 1.8 mm Incisional Surgery

Abstract Microincision cataract surgery (MICS) is an approach to cataract surgery through incision less than 1.8 mm with the purpose of reducing surgical invasiveness, improving at the same time surgical outcomes. The main confirmed advantages of MICS are the control and avoidance of surgically induced corneal astigmatism and the decrease of postoperative corneal aberrations. MICS has been demonstrated to be minimally traumatic surgery, providing better postoperative outcomes than standard small incision phacoemulsification. High degree of surgical innovation, use of advanced phacoemulsification surgical platforms with pressurized fluidic control and new surgical instrumentation, allow doing very sophisticated cataract surgery. MICS favors the use of fluidics, reducing the use of phacoemulsification power. Bimanuality provides opportunity to do manipulation in anterior chamber area easily and much more comfortably than with standard coaxial technique. Today, surgery is performed through 1 mm incision. The use of the modern MICS intraocular lens (IOL) requires incisions of 1.8 mm. The increased availability of MICS IOLs allows to select the best IOL as per the demand of the patient. Long-term stability of the MICS outcomes and wide range of surgical capacity makes MICS the most modern and adequate approach to minimally invasive cataract surgery. Introduction Cataract surgery has experienced a large transformation during the last decades. This transformation has been in response to increased refractive requirements of patients and ophthalmic surgeons. New technology has allowed for unlimited development of the surgery technique and surgery tools. Refractive results of the surgery and new intraocular lens (IOL) technology has gained popularity among patients wanting to remove opaque lens. The need to improve surgical outcomes has led to further development of the surgery technique.

The driving force of cataract surgery development was incision size reduction. The trend to diminish incision size contributed to the development of the phacoemulsification machine, lasers and surgical tools. This evolution of eye surgery had led to development of bimanual cataract surgery with incision size lower than 1.8 mm. Separated irrigation and aspiration approved to use fluidics as a powerful tool and in this way use less phaco energy during each surgery. The reduction of the energy allowed diminishing the aggressiveness of the cataract surgery and improved surgical outcomes. Microincision cataract surgery (MICS) was described first time by one of the authors named Jorge Ali in 2002 in Spain, as a new concept of cataract surgery based on bimanuality, new tools, fluidics and new concept of surgery technique.[1] Agarwal et al. and Tsuneoka et al. described in parallel this surgical approach to cataract surgery with other denominations such as Phaconit or bimanual phacoemulsification-aspiration.[26] Nowadays, standard incision size in bimanual MICS (Bi-MICS) is 1.5 mm. The surgery is done with the proper set of tools, the efficient phaco machine and the appropriate surgical technique. The use of pressurized inflow of fluid is obligatory for MICS. We use precise irrigating choppers and I/A handpeaces which are dedicated to this size of the incision. Limitation of the MICS is based on the IOL technology. Until now we have only few IOLs meeting 1.5 mm MICS requirements. The surgical technique allows us to do MICS with sub 1.0 mm incision with new tool project. Changes also occurred in coaxial phacoemulsification. The width of the phaco tip and the sleeve was reduced to 1.8 mm. Coaxial MICS (Co-MICS) belongs to the family of MICS. It does not have all the advantages of bimanual surgery but this technique allows implanting MICS lenses through the 1.8 mm incision. MICS has gained popularity among surgeons. MICS surgery is well described in literature and large numbers of articles evaluating this novel surgical method are available. Many surgeons describe MICS as a favorable technique because this is not only the novel surgical technique but it has many advantages not available for standard coaxial or micro-coaxial phaco technique.[7] The future trends in cataract surgery will focus on bimanual cataract surgery. The advantages of Bi-MICS surgery technique over the previous techniques are as follows: Smaller incision low impact on corneal biomechanics[810] less surgically induced astigmatism (SIA)[11,12] better postoperative corneal optical quality[13] reduce the risk of endophthalmitis lower risk of iris prolapse during the surgery

The separation of irrigation and aspiration unlimited possibility of the fluid stream managing[5] improves efficiency of the fluid managing system improves access to nuclear fragments[14] energy savings technique[12,1517] The flexibility of the two incisions bilateral access to nuclear fragments[18] better access to the anterior chamber[14,18] easier capsulorhexis and hydrodissection The small size of the instruments; allows better intraocular view The separate irrigation steam may be used to protect the posterior capsule[19] maintain stable AC during whole surgery.[20] In the authors' opinion, the only limitation of this surgery is time-consuming learning curves. Each transition needs to be supported by well-based knowledge and practice. This is the reason why many surgeons in Europe are switching to MICS technique. So far, 16% of the European MICS cataract surgeons have replaced their older technique with MICS. Bi-MICS is different from coaxial phacoemulsification. Learning curves is crucial to become MICS surgeon. Principles of MICS Generally, the principles of the MICS surgery are the same as the standard coaxial cataract surgery. Bimanuality is the main advantage. This gives us chance to extend the limits of surgery. We have easy access to the all parts of the anterior chamber from practically 360. The MICS technique reduces manipulation in normal and complicated cases in the anterior chamber. MICS concept is as follows: 1.5 mm trapezoidal incision: trapezoidal shape of the incision protect wound from deformation during manipulation at an incision size larger than 1 mm. If incision size is lower than 1 mm incision does not require this profile;

Closed and stable anterior chamber: using separated fluid infusion in one incision we can maintain anterior chamber stable during whole surgery time while second incision can be used to phacoemulsification, removal of the masses or IOL injection; Increased use of vacuum: bimanual surgery can diminish use of ultrasound (US) power to break the masses. Instead of the US, we can use high vacuum in the phaco tip with proper use of hydrochopper; Use of pressurized infusion to balance fluidics: MICS hydrochopper is prepared to deliver fluid to anterior chamber with 6070 ml/min. This amount of the fluid is sufficient to fill the AC when we use vacuum 500 mm Hg to break the cataract masses. Gas forced infusion is used in MICS to provide more security in surgery. High infusion stabilizes the anterior chamber; Decrease use of US power settings: high vacuum and high volume of the fluid infusion can be very helpful in breaking the nucleus. For this reason, we do not need US power to break the masses in many situations; Bimanual use of specific MICS instruments: using two independent tools in both hands we can increase the range of surgery. Two opposite incisions give us opportunity to get free access to iris adhesion or difficult capsulorhexis from each side. Use of MICS IOLs: small incision allows to implant only MICS IOLs, without enlargement of the incision.

Bi-MICS Technique
Bimanuality in MICS Absence of the main incision facilitates planning of the two side small incisions. It is important to put incisions on the axis of the corneal astigmatism. Two incisions put on the axis of 90 spread symmetrical force of the corneal biomechanics. SIA by MICS is generally neutral.[12] Proper incision planning and use of limbal relaxing incisions may lead to refractive neutrality of surgery and improve corneal image quality.[21] Two side incisions may facilitate continuous curvilinear capsulorhexis (CCC). It is quite challenging to do incision of 1.5 mm while performing capsulorhexis. MICS capsulorhexis forceps help in tearing the capsule with ease. In case of complicated capsule tear, the angle and side of the forceps can be changed to enhance CCC. Great advantage of the bimanuality can be seen in the nucleus fragmentation. Hydrochopper with the hook help with mass breakdown and maintains distance of the posterior capsule from the phaco tip. Aspiration of the masses is much easier than in the standard technique. Two equal incisions give the opportunity to choose the better incision to implant the lens. While selecting the incisions for IOL implantation, the rule of the dominant incision to diminish the corneal astigmatism is followed.[22] Incision

Diminishing of the incision is minimization of the surgery trauma. Diminishing incision size should minimize surgical trauma. Smaller incisions should diminish the wound recovery time. Probably decrease of incision should minimize deformation of the cornea and inflammation of the eye. Idea of incision minimization provoked progress in cataract surgery. Surgery with incision under the 1.8 mm needs to be performed in nonstandard coaxial way. Bimanuality provokes to open two symmetrical clear corneal incisions. Incision size symmetry allows us to freely operate from each side. Access to each part of the anterior chamber is smooth. Performing the regular capsulorhexis is easy from right and left sides. To perform MICS incision you need calibrated knife. Calibration is required in two planes. First is the incision shape. Internal incision should be shorter than external one. Difference should be about 0.2 mm. Trapezoidal shape of the incision allow us to perform surgery without corneal damage. Trapezoidal shape facilitates horizontal movements of the tools or phaco tip. Internal incision seals the wound and wider external incision facilitates movements. Corneal traumatism was eliminated by this way. There is one more advantage of the micro incision. Incision lower than 1.8 mm allows to close wound without any complication. This dimension of the incision is the self-sealing incision. They are closed after the surgery spontaneously or with small amount of hydratation. This is particularly important for the post-SIA and aberrations.[23] The wound integrity and the self-sealing properties of the MICS and coaxial incisions are currently one of the most important agents in the endophthalmitis prophylaxis.[24] On the other side, Can et al. described higher percentage of Descemet membrane detachment in the MICS group.[8] Elkady et al. did not show any difference between MICS and coaxial groups in incision integrity after surgery using optical coherence tomography.[9] Irreversible changes may affect the cornea. Every incision of the cornea evokes the change of corneal curvature. Kaufmann et al. confirms that MICS incision offers astigmatic neutrality in the cataract surgery, it supports the idea of MICS as the refractive procedure.[11] The authors of this study proved that MICS and microphaco provided similarly good incision quality and optically neutral incisions. The MICS incision respected corneal prolateness more, with less corneal edema in the short term and less induced corneal aberrations in the long term.[24] In the other studies, Tong et al. supported the perfect MICS optical result. Cataract surgery-related changes in corneal wavefront aberrations were dependent on incision size. The MICS technique had advantages over the small-incision cataract surgery (SICS) technique in minimizing the destructive effect of the large incision size on the optical quality of the cornea.[13,25,26] Several studies report significant reduction in the hysteresis CH and CRF after cataract surgery postoperative period. In the study by Ali et al., incision smaller than 1.5 mm provides more stable CH than coaxial phacoemulsification incision. MICS provides more stable cornea than deformation and applied force overtime.[27] One more advantage of the small incision is IFIS reduction. Moore and Goggin describe MICS as the stable technique which can suppress floppy iris prolapse during surgery[20] (Table 1).

Continuous Curvilinear Capsulorhexis


Performing capsulorhexis in lens refractive surgery is crucial for proper lens position in postoperated eye. Multifocal lenses, toric lenses are most susceptible to IOL displacement. For this reason, capsulorhexis should be smaller about 1 mm than IOL

optic dimension. Major capsulorhexis can provoke displacement of the IOL. Lower capsulorhexis can provoke fibrosis or additional aberrations. MICS capsulorhexis is performed by MICS capsulorhexis pencete (Figure 1). To perform capsulorhexis through 1.25 mm incision the micro forceps is obligatory (Figure 2). Nowadays, there are various types of forceps available. The authors prefer Katena Ali MICS forceps (Figure 3). This is not only the first MICS tool, but is also considered for construction. The advantage of this forceps is short working arm. This is important for small dimension of the incision. Long forceps working arm can hook incision and provoke problems with fluency of the CCC tear. The pointed catch on the top of the forceps facilitate first tear of the capsule. During each capsulorhexis, it is essential to maintain the stable anterior chamber. The disproportion between incision and tool can lead to the OVD leakage during the CCC and tearing the capsule outside. With the 1.25 mm incision and 23G instrument practically it does not happen. MICS capsulorhexis has great advantages in the complicated cases. Bimanuality provides easy access to the all parts of the capsule from both sides of the incision. This means that we can do CCC from the 360 entrance. This is important with subluxated cataracts, anterior capsule pathology, synechias with iris, shallow anterior chamber.

Hydrodissection
Hydrodissection as well as delineation is important with each type of the cataract surgery. As always, one should remember about washout of the viscoelastic from AC before hydrodissection. Small and closed MICS incision can inhibit outflow of the viscoelastic during irrigation of the cataract masses. That can provoke hypertension of the AC and be harmful for the capsular bag.

Prechopping
Prechopping is very important for the MICS cataract surgery. This is not only for easy masses breakdown but is crucial for energy reduction, maneuver reduction and time reduction surgery. Thanks to prechopping, we can diminish US energy delivered to the eye. Four or eight parts of the fragmentized nucleus are much more easy to aspirate with the small amount of fluid. Prechopping can facilitate the surgery.[28] This can be done by Ali-Scimitar MICS Prechoppers (Katena Inc., Denville, NJ, USA). The shape of Scimitar Prechopper is designed to perform and facilitate the 700 microns surgery.

Performing prechopping is easy with the two symmetrical prechoppers. Ali-Rosen prechoppers have curve ends with the internal cutting edge. MICS allow performing prechopping with facility. Two opposing incisions allow to enter with two prechoppers, place them in the crossed position and cut nucleus without any asymmetrical pressure on the lens zonula. After the first cut, the nucleus is divided into two parts. With the prechoppers, the nucleus is rotated about 90 and once again the nucleus is cut. Now there are four equal parts of the nucleus. This can be repeated for the next divide. These four parts are sufficient to aspirate masses

Phacoemulsification & Power Modulation


Nucleus is divided minimally in four parts after prechopping. That's why there is no need to grove or divide nucleus in MICS. There are only four quadrants to break and aspirate. First hand is for phacoemulsification handpeace. Unsleeved tip for break and aspirate masses in MICS are used. Phaco tip size and incision size should be selected to eliminate leakage in the incision. For 0.9 mm phaco tip the internal diameter of incision should be less than 1.2 mm (Figure 4). Second hand is for MICS irrigating chopper. This tool performs two basic tasks. Irrigating chopper provides fluid to the anterior chamber. High vacuum provoke high fluid demand, but only few irrigating choppers on the market fulfill MICS fluid conditions. Ensuring the constant supply of fluid to the eye is important (Figures 59).

High fluid flow:


Cools anterior chamber; Stabilizes anterior chamber depth; Stabilizes posterior capsule; Facilitates breaking masses.

For MICS, the authors use hydromanipulator Ali MICS irrigating Stinger made by Katena (Figure 10). This tool fulfils all MICS demand. It provides more than 60 cc/min fluid, which is sufficient for safe MICS surgery. With this tool anterior chamber is stable and the cooling system functions well. On the end of the chopper is hook. This hook is very helpful for breaking masses, dividing hard quadrants and crush masses that clog the tip. This chopper has one more great advantage; the outlet of the fluid is directed downward. This idea of repulsion capsular bag works. Direction of the fluid can protect the corneal endothelial cells because fluid turbulences in the AC are far from endothelium. With the Ali chopper, the conditions are stable and safe in the anterior chamber.[19]

One of the most important parts of the surgery is machine power modulation. For MICS surgery, high values of fluidics but low values of phaco power are used. These settings are very important to avoid complications resulting from the high US energy delivered to the eye during surgery. Energy saving systems are necessary to MICS and can improve the efficacy of surgery. Very short power modulation techniques such as hyper pulse and ultra pulse dramatically decrease the potential for wound burn during MICS because heat penetrates the cornea during the on-time cycle but decreases during the off-time cycle, cooling the phaco tip and cornea. Additionally, short pulse energy may be more effective because it produces more cavitational energy than continuous power. New Constellation platform from Alcon use torsional phaco handpiece to diminish energy.[18] This device has new system of the pump which can provide sufficient vacuum or fluid flow on each stage of surgery. Powerful Venturi Pump is designed to generate pressure of 650 mm Hg. It has excessive power which is rarely used. Software of Constellation has been improved in relation to Infinity and gives us opportunity to program practically all parameters needed. Constellation has important advantage over most platforms on the world market. It has built-in gas forced infusion (GFI) system. The main parameter to program is infusion volume, but we can also program the expected intraocular pressure with the compensation limit. This machine gives us opportunity to program fluidics in a more advanced way. Constellation has powerful pump and torsional phaco handpeace that makes this machine one of the favorable in MICS (Table 2). Stellaris PC from Bausch & Lomb has longitudinal phaco motion handpiece. It has advanced system of the phaco power control, powerful Venturi pump with GFI system, stable chamber system fitted as standard tubing and it makes this machine work very well and is ideal for MICS (Table 3). Ali et al. compared study of the MICS and coaxial phacoemulsification and showed large difference between amounts of energy delivered into the eye. The EPT of the

MICS surgery was more than four-times lower than in the coaxial group and the astigmatism was almost three-times lower than in the coaxial group. This means that intraocular injury connected with the phacoemulsification should be lower in the MICS group.[12] Kurz et al. indicated in publication decrease of phacoemulsification time in MICS group compared with coaxial surgery.[29] Kahraman et al. showed decrease of phacoemulsification time in the MICS group compared with coaxial group (p = 0.001). [30] Tanaka et al. showed lower ultrasonic output in the bimanual group than in the coaxial group. Tanaka et al. correlated it with better efficiency of nuclear treatment, including nuclear compliance, crushing and flexor hinge in the case of bimanual procedure.[31] The other studies did not show difference in the total surgery time between MICS and coaxial phaco.[12,32] Crema et al. showed the total US time was lower in the coaxial phacoemulsification group than in the MICS group; the means were 0.50 min 0.33 (SD) and 0.82 0.39 min, respectively. The mean US power was similar between groups (mean 10.1 3.76% and 10.0 4.0%, respectively).[33] Nowadays, MICS and Micro-coaxial phaco can also be compared. Cavallini et al. showed shorter total surgery time (p = 0.04) and lower BSS consumption (p = 0.004) in the MICS group.[34] Yu et al. published the meta-analysis of the EPT in the MICS and coaxial group.[15] In most of the analyzed studies (6:1), EPT and the power settings were statistically lower in the MICS group (Table 4). The phacoemulsification energy always affects the corneal endothelial cells. A comparative study of the endothelial cell density by Wilczynski et al. showed that there was no difference in the MICS group and micro-coaxial group.[35] Kahraman et al. evaluated the endothelial cell loss in the MICS and coaxial group but the results showed the minimal difference in both groups. There were no statistically significant differences between preoperative and postoperative anterior chamber flare and endothelial cell loss. [30] No significant differences in corneal endothelial cell loss or endothelial morphology were found between MICS and standard incision techniques in the study by Mencucci et al..[32] Morphology of the cells was not different in the MICS and coaxial group in the study by Mencucci et al. or Kahraman et al..[30,32] The comparative study by Crema et al. indicated lower cell lost in the coaxial group. The mean central corneal endothelial cell loss at 3 months was 4.66 6.10% in the coaxial phacoemulsification group and 4.45 5.06% in the MICS group and at 1 year was 6.00 6.72% and 8.82 7.39%, respectively. Postoperative inflammation in the anterior chamber evaluated by laser flare photometry was the same in MICS and coaxial groups in various studies.[12,29,30] The studies by Yu et al. and Wilczynski et al. do not indicate differences between both groups in the endothelial cell loss (Table 5).[15,36] Wylegaa et al. noted lower CCT in MICS group than in the coaxial phacoemulsification group which can be correlated with lower EPT time.[37] Kurz et al. described MICS as the safe technique in complicated cataract cases. The percentage of the complications did not alter than in the coaxial phacoemulsification but EPT was significantly lower than in the coaxial group.[14] The latest analysis by Kim et al. does not demonstrate difference in percentage of the intraoperative complications between MICS and coaxial phacoemulsification of hard cataract surgery with 180 eyes. Moreover, they published data of the statistically

significant lower endothelium loss, central corneal thickness and lower phaco energy in MICS group.[38]

Fluidics
Eye surgery is closed space surgery. The amount of fluid pumped to the eye is equal to the fluid aspirated during the cataract surgery. We can only change parameters of the pressure. MICS surgery is non-leakage surgery, so we can modulate irrigating pressure and vacuum to take advantage of this additional tool. High infusion maintains anterior chamber stability. Infusion about 120140 mm of water is a minimal value of save. The use of pressurized inflow of fluid by GFI is obligatory for MICS. The continuous flow of the infusion liquid is supported by the gas which is delivered with the pressure to the infusion bottle. The GFI helps to stabilize and maintain the inflow of the liquid on the high level. This keeps the anterior chamber constant and permits to cool the tip. It equilibrates the IOP during the whole surgery. Some of the platforms such as Accurus, Millennium, Stellaris, Megatron are supported by internal pump. Infinity platform needs to be supported by external air pump connected with the air filter. This amount of the fluid inflow with capacity of the MICS dedicated tools causes the surgery harmless, easy to predict. This means that nowadays postocclusion surge syndrome is not as harmful as during first years of the phaco surgery. This was a very dangerous situation. After the masses breakdown near the phaco tip the high vacuum provoked surge and pressure drop dramatically in the anterior chamber. This is correlated with power of the fluid pump and elasticity of the tubes. Most of the companies which produce phaco machines try to eliminate this problem by changing the pump software and introduce rigid drains. New phaco machines have very efficient pumps. There is tendency to increase efficiency of the pumps. Safety requirements resulted in the development of the new software in order to efficiently manage the pumps. Now we can change the parameters of the construction of the vacuum, and reaction of the pump for sudden drop in pressure. Software control panel can be found in Constellation (Alcon), Stellaris PC (Bausch & Lomb) and Megatron S3 (Geuder). Main method to increase the fluid efficiency is to increase the fluid inflow. Proper MICS irrigating chopper provides a sufficient amount of the fluid in most of the situations in cataract surgery, but connecting air pump to the irrigation bottle can increase mechanically the amount of the delivered fluid. This idea of the air forced infusion works well in machines with pressurized air such as Stellaris PC, Megatron S3. In the case of the powerful pump, flow restrictors can be used to diminish surge syndrome. This system is based on the internal membrane in the tubing system. Membrane with small holes means that only certain amount of water can flow through the system. The larger elements of the nucleus are retained on the filter. Cruise Control (Staar Surgical Co.) and Stabile Chamber System (Bausch & Lomb) are the only available flow restrictors. These systems connect to the aspiration tube, behind the phacoemulsification handpiece and allow to increase vacuum and break cataracts with the greater degree of the safety. Vacuum setting values of 500 mm Hg are safe and comfortable for surgeon. Small filters restrict the flow and surge does not exceed the

limit values. The possibility of the AC collapse and rupture of the posterior capsule is practically eliminated.[39]

Co-MICS Technique
Coaxial microincision phacoemulsification Co-MICS does not differ much from standard coaxial phacoemulsification and the learning curves are easy. The most important difference is width of the incision (1.8 mm). Phaco tip and sleeve have very thin shape. Phaco tip can have extended end (Oertli, Bausch & Lomb) or longitudinal shape with incisions on the external side (Bausch & Lomb). These accessories facilitate inflow of the fluid to the anterior chamber by the coaxial tunnel. The volume of the inflow fluid is also restricted by the width of the coaxial sleeve. This type of cataract surgery needs to have high inflow fluid pressure to protect anterior chamber from collapse after surge. The outflow of the fluid is restricted by the phaco tip inner width. To ensure flow surgeon has to increase vacuum. Co-MICS is also high-volume asymmetrical surgery. All surgeons agree that this is no longer standard coaxial astigmatism induction, but still higher. Impeded tip flow increases the demand for US power. To break the masses we have to use more US power than in Bi-MICS. Here fluidics does not ensure sufficient power to act as powerful tool. Therefore, the comparison of both techniques shows lower efficiency of coaxial technique. This does not mean that it is worse, but does not provide additional benefits as Bi-MICS.

MICS Intraocular Lenses


The MICS IOLs can be safely implanted through incision less than 1.8 mm. The only limitations for MICS procedure is the small amount of the MICS lenses. Up to now there are only few lenses performing MICS. It is correlated with very high technical and optical requirement. MICS lens should meet the following requirements:

Be implantable with sub 1.8 mm MICS incision (Figure 11); Be flexible and compression tolerated without destruction; Optics should not be damaged in MICS cartridge; Haptics after unfolding must keep the proper position in the bag; Perfect long-term stability in the bag; Posterior capsular opacification (PCO) protect system; Aberration-free optic.

Despite the large number of the IOLs, only a few meet the MICS requirements. Most of the existing IOLs do not meet the sub 1.8 incision demands. Lenses which fulfill the MICS demand on the market are listed in Table 6. Zeiss MICS Group IOLs Most diverse group of the MICS lenses are Carl Zeiss MICS lenses. To this group belong six different lenses which can be implanted through 1.5 mm incision. These lenses are known as the Acri.Tec MICS Family IOLs. There are multifocal lenses, toric lenses, monofocal lenses. All the Zeiss lenses are the lenses with the optical diameter of 6 mm. It is biconvex, equiconvex, non-angled lenses with hydrophobic surface. CT.Asphina IOLs have water content of 25% in the fully hydrated state; these lenses are designed with square truncated edges. The edge thickness corresponds to standard designed IOLs and is in the range 0.250.27 mm. The lens is made from acrylic material, a copolymer of hydroxyethylmethacrylate and ethoxymethacrylate with an ultraviolet absorber. The optic power of this lens range from 0.00 to 32.00 D. AT Shooter A2/2000 with ACM2 cartridge is used to implant lens through 1.5 mm incision. They are very easy to apply. After injection, the lens unfolds very quickly and with the control. It has no tendency to decentration or to tilt. The adhesion between posterior capsule and lens is perfect.[40] Zeiss MICS lenses are one of the most expanded IOL families:

Monofocal aspheric: CT.Asphina; Monofocal spherical: CT.Spheris; Multiphocal aspheric: AT.Lisa; Multifocal toric: AT.Lisa toric; Monofocal toric: AT.Torbi.

Clinical Results. Zeiss MICS lens family IOL are most popular and tested in MICS surgery. In a study by Ali et al., Acri.Smart IOLs implanted in 45 eyes with cataract grade 2, 3, 4 (LOCS III) were operated by MICS. The incision size was 1.46 mm (1.4 1.9). Six months after the operation, 98.9% of the patients had BCDVA 20/25 (0.7 decimal value) or better and 71.3% of the patients had distance UCDVA 20/32 (0.6 decimal value) or better. The safety index for distance vision of the procedure was 2.5 and the efficacy index of the procedure was 1.8. Ninety percent of the patients had a near BCNVA of 20/25 (0.8 decimal value); 60% of the patients had a near UCNVA of 20/32 (0.6 decimal value) or better. The mean add for near was +1.5 D or less in 70% of cases and was +2.0 D in 26% of cases. The safety index for near vision of the procedure was 1.4 and the efficacy index of the procedure was 0.9. It indicates that Acri.Smart has pseudoaccommodative ability. In this study, none of the lenses showed any change in position, decentration, tilt and PCO.[41] The results of the investigations for the multifocal toric LISA 909M are already available. Ali et al. reported excellent postoperative UDVA outcomes with this lens. This lens also gave acceptable intermediate vision more than 0.3 log MAR. Rotational stability of this lens was lower than 6%.[42] New toric lens AT Lisa 909M seems to be very promising lens correcting moderate corneal astigmatism after cataract surgery. Mojzis et al. showed excellent data of the AT.Lisa 909M implantation in the MICS patient group. Mean angle of error was 0.37 5.50 and -4.51 13.16 for the MICS and mini-incision groups, respectively (p = 0.09).[43] Alfonso et al. described results of the cataract surgery and implantation Acri.Lisa 366D IOL. The results showed excellent safety index of this lens for distance and near and excellent results of the contrast sensitivity.[4446] Spyridaki et al. showed lower PCO and YAG capsulotomy rate after MICS in the patient with Acri.Smart 48S.[47] Akreos AO MI60 Akreos AO MI60 Micro Incision is a hydrophilic acrylic lens with 26% hydration rate. Optic diameter of the lens is 6 mm and has a 360 posterior ridge-barrier to prevent PCO. Haptics geometry consists of four-point support system, haptics angled at about 10. Akreos MI60 has an aspherical optic and has neutral spherical aberration. Akreos AO MI60 can be implanted with a 1.8 Viscoglide cartridge and Viscoject Lens Injection System (Medicel AG, Widnau, Switzerland). This type of lens has no tendency to decentration or PCO (Figure 11).[48] In the study by Can et al., MI60 lens had excellent optical quality, capsular stability and low rate of PCO. In the period of 3 months, no one eye needed YAG laser capsulotomy, [48] but Selvam et al. showed that after 30 months of surgery 20% of the patients needed laser YAG capsulotomy because of the high rate of PCO.[49] Ali et al. showed excellent MTF of this lens with wavefront analysis.[50] Physiol MICS IOLs MicroSlim and SlimFlex MICS IOLs (PhysIOL, Lige, Belgium) is a hydrophilic acrylic lens with biconvex optics. Optic diameter is 6.15 mm, and overall diameter is 10.75 mm. The angulation is 5. The power of the lens range from +10.0 D to +30.0 D.

This lens can be injected using Viscoject Injector and 1.8 Viscoglide cartridge (Medicel AG). No clinical data are available for this lens. Acrimed MICS IOL AcriFlex MICS 46CSE IOL (Acrimed GmbH, Berlin, Germany) is made of 25% acrylic hydrophilic. The superficial is hydrophobic. The lens diameter is 11.0 mm and optic diameter is 6.0 mm. This is a monobloque type lens with perforated haptics. The angulation is 0. The optic is biconvex with sharp edges. The lens is available from +15 to +27 D. The clinical data are not available for this lens. Mediphacos MICS IOL Miniflex IOL (Mediphacos Ltda., Minas Gerais, Brasil) is also new MICS surgery lens that can be implanted through 1.8 mm incision. The material is Flexacryl Hybrid Acrylic which brings together hydrophobic and hydrophilic monomers. The optics is aberration neutral. The lens can be implanted through 1.8 mm incision using a docking technique. The lens was presented on ESCRS 2008 in Berlin by Carlos Verges. Presbysmart.plus Presbysmart.plus is new intraocular lens dedicated to MICS. This lens can be implanted with 1.5 mm incision. This is pupil diameter independent diffractive multifocal IOL. This is one piece, 26% water content, equi-biconves, aberration-free lens. The diameter of the lens is 11 mm with 6 mm optical part. Finally, the authors conclude that MICS IOLs is not only the normal classic IOL which is adapted to MICS incision. These lenses are the other type of IOLs. New technique and new idea of the construction lead to create thin and stable MICS IOL with the optical quality as good as standard IOLs.[51,52]

MICS Results
Surgically Induced Astigmatism & MICS The optical quality of the cornea plays an important role in recovery of visual function after cataract surgery, and this is determined by combination of corneal and internal aberrations generated by the IOL and those induced by the surgery. These corneal refractive changes are attributed to the location and size of the corneal incision. The smaller incision, lower aberrations means better optical quality. Degraded optical quality of the cornea after incisional cataract surgery would limit the performance of the pseudophakic eye. Thus, it is important not to increase or to induce astigmatism and/or corneal aberrations after cataract surgery. Symmetrically placed two small incisions give MICS an advantage over rest of the cataract surgery techniques because 1.5 mm incision is practically neutral for corneal biomechanics. Even with MICS, it is possible to achieve reduction of the astigmatism and higher-order corneal aberrations if the incisions are placed on place corresponding to the main axis of astigmatism.

Great advantage of MICS is the reduction of SIA and that the microincisions do not produce an increase in astigmatism when compared with conventional 3 mm phacoemulsification (Figure 1). The shorter the incision, the less the corneal astigmatism, as it was estimated that the magnitude of the SIA studied by vector analysis was around 0.44 and 0.88 D, rising as the size of the incision increased. This is considered important because cataract surgery today is considered more and more a refractive procedure. Also, small-incision surgery (3.5-mm incision without suture) does not systematically degrade the optical quality of the anterior corneal surface. However, it introduces changes in some aberrations, especially in no rotationally symmetric terms such as astigmatism, coma and trefoil. Therefore, one has to expect better results and lesser changes with sub 2 mm incision (MICS). This is supported by the finding that the corneal incision of <2 mm had no impact on corneal curvature. It is important to go hand in hand with the modern concept of making cataract surgery a refractive procedure, by controlling and even decreasing astigmatism and higher-order aberrations (HOAs) by using MICS.[12] MICS sub 2 mm incision effectively decreases the induction or changes in corneal SIA during cataract surgery (Figure 12).[12]

Dick in his study confirms better clinical outcomes of MICS versus coaxial group. MICS group patients showed earlier improvement in BCVA and less SIA.[16] Comparative study of Can et al. also supports less SIA production by MICS.[17] Wilczynski et al. did not notice statistically significant difference in SIA production in both the compared groups.[53] Kaufman et al. did not noticed any statistical difference in keratometry between pre- and postsurgery topographic examination (Table 7).[11] Corneal Aberration With MICS A demand for the cataract surgery obliges to not only removal of cataract nucleus but also to improve optical quality of the eye. Market for intraocular lenses gives us opportunity to implant perfect lenses which can diminish total HOAs of the eye. The final visual function is determined by the aberrations produced by the implanted intraocular lens and corneal aberrations changed by the postsurgical incisions.

Therefore, the best quality of lenses for cataract surgery should be suggested in order to improve patient's visual outcome. Elkady et al. and Ali et al. in their prospective cumulative interventional nonrandomized, non-comparative study of 25 eyes of 25 patients showed that after the MICS incision smaller than 1.8 mm, there was no statistical difference in corneal power, corneal astigmatism before and 3 months of follow-up after surgery.[54] The RMS value of the total corneal aberrations decreased slightly after MICS (mean 2.15 2.51 m preoperatively, 1.87 1.87 m at 1 month and 1.96 2.01 m at 3 months); there was no statistically significant difference between the two follow-up visits (both p = 1.00, Bonferroni). Analysis of individual Zernike terms showed a mean astigmatism of 0.85 0.74 m preoperatively, 0.65 0.44 m at 1 month and 0.69 0.46 m at 3 months and a mean spherical aberration of -0.11 0.25 m, -0.09 0.25 m and -0.19 0.13 m, respectively. Coma decreased (mean 0.45 0.40 m preoperatively, 0.39 0.36 m at 1 month and 0.42 0.44 m at 3 months, respectively); there was no statistically significant difference between the two follow-up visits (both p = 1.00, Bonferroni). The mean HOA was 0.47 0.26 m preoperatively, 0.59 0.32 m at 1 month and 0.54 0.25 m at 3 months; there was no statistically significant difference between the two follow-up visits (both p > 0.47, Bonferroni).[54] All aberration values except HOA decreased slightly, with no statistically significant differences between the follow-up visits. All aberration values were stable for 3 months after surgery, indicating that successful MICS depends on preventing induction of HOAs as well as a surgically neutral and stable procedure. Successful MICS gives visual quality equal to that in persons of the same age without pathology and leads to good patient satisfaction (Figure 3).[54] Denoyer et al. compared MICS with conventional coaxial surgery. This study showed that MICS could improve the optical performances of the pseudophakic eye reducing in 3 months surgically induced corneal HOAs. The postoperative root mean square of 3rd to 6th was lower in MICS group 0.705 0.285 versus 0.956 0.236 m in coaxial group and it was significantly different (p < 0.001) and the root mean square for the 3rd to 6th order ocular aberration was lower in MICS 0.308 0.122 m versus coaxial group 0.488 0.172 m with significant difference (p = 0.002).[55] Can et al. compared MICS with Co-MICS. They found that only MICS group did not alter corneal aberrations after the surgery, which confirm aberration neutrality of MICS surgery.[56] Tong et al. in a group of 80 patients proved less cataract surgery-related changes in corneal wavefront aberrations after MICS than after coaxial surgery. Coaxial group had greater changes in oblique astigmatism, trefoil, vertical tetrafoil, RMS and higher-order RMS of corneal wavefront.[25] New comparative study done by Ali et al. of the corneal aberrations after MICS and 2.2 mm coaxial surgery showed that 2 mm incision was the safe limit of the corneal degradation. MICS significantly produced less changes in coma and higher-order aberrations compared with coaxial phaco (Table 8 & Figure 13).[57]

Conclusion
Ten years of MICS surgery give us opportunity to evaluate efficacy of this surgical technique. Every fifth surgeon knows and uses this method to do cataract surgery. The advantages of MICS in the field of the refractive result as astigmatism control and aberration neutrality are supported by many papers of the various authors as described. However, Bi-MICS seems to be superior over the other surgical techniques because of the better refractive result, better fluidics, greater manual control and lower surgical time. As per the authors' opinion, this technique is simple and safe to use. MICS is easy to learn and perform for cataract surgeons. The continuous reduction of the incision size is the future of the cataract surgery. MICS is not limited by the incision size. Now micro-MICS is also gaining popularity. Technology for the sub 1 mm incision is available with MICS.[58] The development of the corneal femtosecond laser resulted in use of this laser in cataract surgery (Figure 14). It is possible that present application of laser in lens surgery diminishes the incision and reduces the use of US. Phaco handpiece elimination will allow further reduction of the incision size. Current attempts are so promising that it gives hope to change the current method of lens emulsification in a short period of time.

Expert Commentary
MICS is one of the ways of the modern cataract surgery. The surgeons' initial problems with transition to MICS surgery are quickly overcome because of the power that comes from the simultaneous use of fluidics and bimanuality. The MICS bibliography of the past 10 years is still growing. Expert opinions differ in many cases according to MICS technique, but most of the publications agrees on the fact that MICS gives more opportunity to achieve advanced refractive result of the cataract surgery with less perioperative injury. MICS surgery does not increase corneal endothelium loss, corneal edema, inflammation of the anterior chamber or incision healing process in comparison with coaxial cataract surgery technique. MICS surgery in contrast to coaxial technique decreases effective phacoemulsification time during surgery, decreases SIA and corneal HOAs. MICS should be considered as a preferable surgical technique in case of refractive lens exchange, multifocal IOL implantation or toric lens implantation to improve the surgical result.

Five-year View
The diminishing of the corneal incision is a trend of the modern cataract surgery. MICS with bimanual technique is prepared for the incision lower than 1.5 mm. Sets of the instruments to perform cataract surgery through incision lower than 1 mm exist. There is a need to develop new IOL technology. This barrier is very difficult, because it is correlated with the search of new material that can be compressed and decompressed without losing the optical quality.