Global Perspectives on Manual Small Incision Cataract Surgery Training

Manual Small Incision Cataract Surgery (MSICS) is recognized as a transformative technique for cataract extraction, particularly in low-resource settings. As the demand for cataract surgery continues to rise globally due to the aging population and increased life expectancy,¹ innovative approaches to MSICS training have emerged across the globe. These training models not only provide immediate benefits in underserved areas but also offer valuable lessons that could be adapted for training cataract surgeons in the United States.

Why MSICS?

MSICS is an effective alternative to phacoemulsification. The cost-effectiveness, accessibility, and high success rate of the procedure make it an ideal solution for addressing cataract blindness. Although largely used in areas of the world that lack sophisticated equipment and advanced surgical technologies, MSICS is useful in myriad settings and situations, including eyes with extremely dense (eg, white and black) cataracts,² extensive corneal opacity, pseudoexfoliation, and iridofundal coloboma.^3 4

Studies also have shown that mastering MSICS may help reduce the learning curve with phacoemulsification,⁵ a cataract extraction technique routinely used in economies like the United States with plentiful resources. Reproducibility of the MSICS technique and successful outcomes after surgery, however, depend heavily on the acquisition of surgical skills and the quality and rigor of surgical training. With the right MSICS training and guidance, visual outcomes and complication rates are similar to those of phacoemulsification. ^{6 7}

Innovative Training Programs

Many countries have adopted innovative models to teach MSICS that combine traditional hands-on surgical training with simulation-based learning. The latter may reduce the learning curve, improve safety outcomes, and enable surgeons to handle complications more effectively.⁸

The HelpMeSee Simulation-based Training Program is a prime example of how to successfully combine instructor-led learning with simulation training, bridging the gap between theory and practice, providing a platform for trainees to refine their surgical technique and enhance their competency and confidence.⁹ During training, individuals perform simulated surgery on the HelpMeSee Eye Surgery Simulator, a VR environment that replicates the intricacies of the ocular anatomy and uses haptic feedback to provide a real-world surgical experience. Additionally, dedicated instructors guide learners through every step, ensuring the trainees develop the practical skills required of the procedure.

A structured simulation program may significantly improve the skills of new surgeons, ensuring they can perform MSICS with a high degree of proficiency.⁹ Countries like Nepal, Ethiopia, and Tanzania have successfully integrated the HelpMeSee model into their surgical training programs. By assessing surgeons based on their performance in simulated environments, these programs ensure trainees master the required skills before moving on to real surgery.

Adopting MSICS Training in the United States

Although this approach to MSICS training has been effective largely in low-resource areas, the competency-based assessment model and rigorous evaluation of surgical skills is just as appropriate for residency training programs in the United States and other developed countries.¹¹

As the United States grapples with rising health care costs and an aging population, MSICS could offer a more cost-effective option for treating cataracts, especially in underserved communities. Incorporating simulation-based learning and competency-based evaluations into US training programs could enhance surgical proficiency, minimize risks to patients, and accelerate the time it takes to produce highly skilled surgeons.

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1. Chen J, Zhu Y, Li Z, et al. Global impact of population aging on vision loss prevalence: a population-based study. Global Transitions. 2024;6:28-36. ↩︎
2. Bourne RRA, Minassian DC, Dart JK, Rosen P, Kaushal S, Wingate N. Effect of cataract surgery on the corneal endothelium: Modern phacoemulsification compared with extracapsular cataract surgery. Ophthalmology. 2004;111:679-685. ↩︎
3. Bhargava R, Kumar P, Sharma SK, Arora Y. Phacoemulsification versus manual small incision cataract surgery in patients with fuchs heterochromic iridocyclitis. Asia Pac J Ophthalmol (Phila) 2016;5:330-334. ↩︎
4. Venkatesh R, Tan CS, Sengupta S, Ravindran RD, Krishnan KT, Chang DF. Phacoemulsification versus manual small-incision cataract surgery for white cataract. J Cataract Refract Surg. 2010;36:1849-1854. ↩︎
5. Lynds R, Hansen B, Blomquist PH, Mootha VV. Supervised resident manual small-incision cataract surgery outcomes at large urban United States residency training program. J Cataract Refract Surg. 2018;44:34-38. ↩︎
6. Venkatesh R, Muralikrishnan R, Balent LC, Prakash SK, Prajna NV. Outcomes of high volume cataract surgeries in a developing country. Br J Ophthalmol. 2005;89:1079-1083. ↩︎
7. Gogate P, Deshpande M, Nirmalan PK. Why do phacoemulsification? Manual small-incision cataract surgery is almost as effective, but less expensive. Ophthalmology. 2007;114:965-968. ↩︎
8. Lansingh VC, Gonzalez PD, Díaz Flores T, Lopez Star EM, Martinez JM. How many cataract surgeries does it take to be a good surgeon? Revista Mexicana de Ophthalmologia (Eng). 2023:10.5005/rmo-11013-0026. ↩︎
9. Ahiwalay C, Lansingh VC, Nair A, Bacchav A, Chavan K. Competency-based training on eye surgery simulator. Accessed September 18, 2024. https://helpmesee.org/wp-content/uploads/2023/10/Competency-Based-Training-on-Eye-Surgery-Simulator.pdf ↩︎
10. Ahiwalay C, Lansingh VC, Nair A, Bacchav A, Chavan K. Competency-based training on eye surgery simulator. Accessed September 18, 2024. https://helpmesee.org/wp-content/uploads/2023/10/Competency-Based-Training-on-Eye-Surgery-Simulator.pdf ↩︎
11. Hutter DE, Wingstead L, Cejvanovic S, et al. A validated test has been developed for assessment of manual small incision cataract surgery skills using virtual reality simulation. Scientific Reports. 2023;13:10655.C, Lansingh VC, Nair A, Bacchav A, Chavan K. Competency-based training on eye surgery simulator. Accessed September 18, 2024. https://helpmesee.org/wp-content/uploads/2023/10/Competency-Based-Training-on-Eye-Surgery-Simulator.pdf ↩︎