WOUND CONSTRUCTION IN SICS

Introduction

 Wound- not just a portal of entry into the

anterior segment
 Cataract surgery has become a form of
refractive surgery offering improvements in
‘best corrected’ and ‘uncorrected’ visual
acuity.
Principles of Wound
Construction

 Basic Objective
 Astigmatism - neutrality
- stability
Variables of Incision

 Location
 Extent
 Form
 Closure
Evolution of Modern Scleral Tunnel

 Dr. Richard Kratz – Scleral pocket incision

 Michael McFarland (1990 ) – First to perform

sutureless closure of scleral tunnel wound

 Paul Ernest – scleral tunnel with internal corneal

lip. It is a modification of McFarland’s wound
technique by carrying forward the tunnel into
clear cornea
Koch’s Incisional Funnel
 Scleral Tunnel

 3 components
 External scleral incision

 Sclerocorneal tunnel
 Internal corneal incision
Components of Scleral
Tunnel
Ideal Incision – External
Scleral Groove

 Location : 2.5 to 3 mm from anterior border

of limbus
 Depth : 1/3 to ½ thickness of sclera
 1.5mm internal corneal lip
Shape of the Incision
Length of External Incision

 Manual SICS
 Inverted trapezoid shape
 According to the size and density of nucleus 6-
6.5mm (7-7.5mm)
 Phaco
 4mm square wound
 Extend according to size of IOL
 5-5.5mm all PMMA IOL
 3.5-4mm for foldable
Instrumentation

 Caliper
 15 no. blade
 Crescent knife
 2.8mm broad keratome
Technique – Scleral Tunnel

 External Scleral Groove

 Tunneling with creation of 1-1.5mm
internal corneal lip of uniform thickness
 Bevel up crescent blade preferred
 Side port entry
 Anterior chamber entry
 Extension of the internal lip of the tunnel
 Avoid button holing of scleral flap and
premature entry into anterior chamber
Side Port Entry

 At 9 ‘0’ clock in clear cornea

 1.5mm from the limbus
 2mm in width
 Uses
 For doing capsulorrhexis
 12 ‘0’ clock cortex aspiration
 Formation of anterior chamber at the end of
surgery
 Anterior chamber entry

 Done with 2.8mm angled keratome

 Dimple down technique
 Be cautious not to damage anterior
capsule or corneal endothelium
Extension of Anterior
Chamber Entry

 Done with keratome

 Length of internal corneal incision should
be more than external scleral groove
Advantages of Scleral Tunnel
 Surgical
 Less incidence of iris prolapse
 Water tight – Decreased incidence of expulsive
haemorrhage
 Advantages to the patient
 Stronger wound permitting greater range in
postoperative activities
 No suture induced FB sensation / astigmatism
Complications of Tunnel
 Anterior Incision – Poor self sealing
effect

Wound leak
ATR Astigmatism
 Management - Suture
 Posterior Incision

 Risk of Bleeding / Premature entry

 Difficulty in nucleus delivery and instrument
manipulation
 Management – Suture for premature entry
Complications – Incision Length
 Short Incision

Difficult nucleus delivery

Endothelial damage, Iris damage

Management – Enlarge the incision with keratome

 Long Incision – Poor Approximation

Wound leak
ATR Astigmatism
Management - Suture
 Complication – Incision
Depth
 Button holing
Causes: - charred sclera from excessive cauterization
- too superficial tunneling
- poor view during tunneling
- blunt crescent blade
- scleral thinning as in high myopia

 Premature entry
Causes: - too deep tunneling
- non-recognition of corneal dome

 Scleral Disinsertion
 Multi-planar
Management –
Button Holing

 Button holing or cut through the scleral roof

 Abandon the original dissection
 Start at the opposite end
 Deeper dissection and sweep laterally
 Avoid bunching of advancing scleral tissue as
the crescent blade advances towards surgical
limbus
 Management of Premature
Entry
 Start fresh with less
depth of dissection
into sclera
 Avoid aggressive
angling of keratome
blade
 Increase the dissection
into clear cornea
 Suture the tunnel
 Management of Scleral
Disinsertion
 Occurs when initial
scleral groove is full
thickness or deep
 Radial suture should
be used to appose the
edges of scleral groove
Suturing of Scleral Tunnel

 Indicated in premature entry and weak

tunnels
 Radial sutures having a vertical
component will cause post operative with
the rule astigmatism
 Horizontal suture is more physiological to
the scleral tunnel and causes less with the
rule astigmatism
Tunnel Complication -
Descemet’s Stripping
 Caused by cannula/keratome tip in the
corneal canal causing intralamellar
hydrodissection (saline / viscoelastic injection
 During tunnel construction
 MANAGEMENT OF DESCEMET’S
STRIPPING
 Management
 Careful instrumentation
 Injection of air bubble beyond the point of
detachment
 Inferior ½ of cornea – reposit with viscoelastics
 Large DM stripping – Full thickness corneal suturing
Complications - Paracentesis

 Too far into cornea / Too small- DM Stripping

 Too periphery into sclera- bleeding
 Too large – Leakage
 Not parallel to iris – Injury to lens capsule / Iris
Temporal Scleral Tunnel

 Indications
 High ATR astigmatism cases

 Presence of superior filtering bleb

Temporal Scleral Tunnel

 Advantages
 Less induced astigmatism as compared to
superior incision
 No brow effect
 Good red glow
 Disadvantages
 Orientation for surgeon
Comparison – Phaco / SICS
Tunnel
 Length of external Incision
 Phaco – 3 - 5 mm
 Manual SICS – 6 - 7 mm
 Width of tunnel
 Manual SICS – dissection is more posterior in sclera and more
anterior in cornea
 Internal opening
 Phaco –equal to external opening
 Manual SICS is larger than external
 Paracentesis
 Instrumental – 2 and 10 ‘ 0’ clock
 Manual SICS – 9 ‘0‘ clock