Description

Cataract surgery has experienced a very rapid evolution in the second half of the last century. Starting from a very well-established intracapsular extraction, basically, the idea of preserving compartmentalization inside the eye, meant to returning to extracapsular cataract surgery. The idea to perform cataract surgery through the smallest incision possible, resulted in the discovery of phacoemulsification by Charles Kelman. Without any doubt, it has been a great invention and has logically become the most- practiced procedure for cataract surgery wherever the required technology is available. But there is a tendency to forget that the cost of the implantation of this technique was very high in terms of complications (and indeed severe ones too), during many years after its discovery. A great deal of technological refinement by the industry was required to literally make these machines less-dangerous to the eye. Also the surgical technique used at this time together with those primitive machines made this surgery rather challenging. Only think of a hard cataract extraction by phacoemulsification with a can-opener anterior capsulotomy. It certainly worked in many cases but the complication rate was rather high. Apart from technical evolution, the human factor played a very important role in improving the results of cataract surgery done by phacoemulsification. The introduction of the continuous curvilinear capsulorhexis by Neuhann and Gimbel many years after the beginning of phacoemulsification, became one of the biggest improvements in any kind of extracapsular cataract surgery. Also the selection and adequate use of viscoelastic devices, has added a great deal of safety to this surgical procedure. The fascination caused by the concept of phacoemulsification made many surgeons think it was the only way to go about performing cataract surgery through a small incision. As a matter of fact, one did not perform cataract surgery any more, but phaco-surgery. The obvious benefits of the small incision, fast recovery and better refractive outcomes, were very appealing. But we all know that the transition from planned extracapsular to phaco- emulsification had, in many instances, a high-cost in both eye integrity and coronary system of the surgeon’s heart. At the same time a small group of surgeons were trying to achieve similar results but using their surgical mind and hands as well as simple, inexpensive instruments rather than fighting with a complicated and certainly expensive ultrasound machine, which very often failed in difficult cases. This often meant either a change to a large incision extracapsular or the acceptance of possible important complications if one persisted in the idea of using the modern ultrasound machine to deal with, for instance, a very hard cataract or several other difficult conditions. Small incision manual cataract surgery has also improved significantly with the passage of time. As a matter of fact similar results as with phacoemulsification can be obtained. Using this approach in difficult cases was still possible without having to enlarge the incision to 10- 12mm. Independency from technology becomes xii STEP BY STEP MANUAL PHACO important in many situations. Also when speaking to surgeons who do or have practised SIMCS, there is a common agreement that transition to phacoemulsification was easy. The intraocular manipulation, respecting the eye structures required by SIMCS makes the difference as opposed to plain transition from planned ECCE to phacoemulsification. It is true that most of the surgeons who have written the chapters of this book are also or even mainly phaco surgeons. With the present ultrasound technology and refined surgical technique, the procedure has become easier and faster as well as very safe even in previously considered very difficult cases. But in my opinion, being able to use this manual approach remains very useful in special cases, when there is no access to advanced and expensive technology, or in cases of surgery performed under very adverse conditions often encountered in developing countries, among others. Taking all of this into account, we greatly appreciate that such an excellent and experienced communicator as Dr Ashok Garg, has combined his effort together with the co-editors Dr Luther L Fry, Dr Francisco J Gutiérrez-Carmona and Dr Amulya Sahu to write this book, with the important contribution of a selected group of experts in this field. The book is mainly dedicated to describe several manual techniques including nuclear manipulation or fragmentation, fragment extraction, strategies in the use of several viscoelastic devices, the use of an anterior chamber maintainer etc. Special chapters deal with the application of this technique in pediatric cataract and FOREWORD xiii difficult situations. A whole chapter on complications and their avoidance is also included. In other words, the reader will find many ideas to either learn or enrich his manual small incision cataract surgery. I would like to give my warmest thanks to Dr Ashok Garg for honouring me with the task of writing the introduction to his book. I am convinced that it will help many surgeons to improve their surgical skills for the benefit of their patients. Carlos Infantes MD

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