One step beyond tomorrow; Ranjan manual small-incision cataract surgery (MSICS) marker - Welcome to the topical, flapless and astigmatism-free MSICS era : Indian Journal of Ophthalmology

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One step beyond tomorrow; Ranjan manual small-incision cataract surgery (MSICS) marker - Welcome to the topical, flapless and astigmatism-free MSICS era

Mishra, Deepak; Dixit, Nitish1,; Ranjan, Pratyush2

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Indian Journal of Ophthalmology 70(11):p 4086-4088, November 2022. | DOI: 10.4103/ijo.IJO_1696_22
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Cataract remains 51% cause of blindness and 33% cause of visible impairment internationally in accordance to information (2010) published by the World Health Organization (WHO). Ninety percent of these populations are currently in poorer parts of the world like southeast Asia and the region of Africa to the south of the Sahara desert, the places where fee stays a constraint for providing best treatment with satisfactory results.[1]

In these communities, blindness is associated with significant incapacity and mortality. It also has profound societal and monetary ill effects via loss of productivity of both the blind patient and the care provider of that blind person. Because of the significant decrement in life expectancy and quality of life for the blind, sight restoration by cataract surgery is most likely one of the least expensive medical interventions with the best visual outcomes.[2]

Phacoemulsification (phaco) is the surgical operation of choice for cataract in the developed world. Several researches have demonstrated quicker healing and better postoperative uncorrected visual acuity due to much less post-surgery astigmatism. Nevertheless, there are no considerable variations in visual rehabilitation, endothelial cell loss, and complication rates when in contrast with manual small-incision cataract surgery (MSICS).[34]

Phaco is often on hands in the developing world to those cataract patients who can privately fund it. Compared with MSICS, phaco requires a sizable capital purchase and higher grant charges per case.[5] Annual phaco machine maintenance is an issue not only of cost but additionally of readily available qualified technical support. Moreover, there is a longer studying curve for new cataract surgeons to master phaco, which is specially challenging in the developing world due to poorer institutional and infrastructural support and lesser hands-on training for ophthalmologists.[6]

Finally, the advanced mature cataracts and brunescent hard cataracts that are so regular amongst poor populations are extra challenging to extract with phaco, and the complication rate is greater in most arms except in most skilled and experienced phaco surgeons. Multiple studies have reported the safety and efficacy of MSICS for tricky cases, such as brunescent or white cataracts, and cataracts associated with phacolytic and phacomorphic glaucoma.[78]

For these reasons, MSICS has emerged as a workable and preferable choice for many such settings. For high-volume cataract treatment with high and comparable quality, the use of MSICS has been popularized in community eye care facilities to efficaciously manipulate and treat the large backlog of cataract-associated blindness. It presents great outcomes at a fraction of the cost of phaco and with shorter surgical time.[9]

When price is not the constraint, phaco frequently remains the procedure of choice for cataract extraction because of the following three reasons:

  1. Shorter Hospital stays due to topical (drop) anesthesia;
  2. Shorter recuperation time due to smaller measurements of incision; and
  3. Lesser requirements of glasses/spectacles after surgery due to smaller size of wound creation and cautious wound development, taking account of steep axis and surgically induced astigmatism (SIA).

Topical MSICS is being carried out by many specialists around the world with notable results. MSICS with greater astigmatic control (comparable to phaco) is seen with carefully locating, shaping, and dimensioning of the incision.

Many researches have established the ideal MSICS incision to be of the following attributes: The anterior restriction of the incision should be 2–3 mm back to the limbus, in Koch’s incisional funnel, to minimize post -surgical operation astigmatism. The size of the incision (the distance between the two ends but not along the curvature) varies from 5.5 to 6 mm. The frown-shaped incision is best suited for MSICS due to the fact that it induces the least astigmatism with much less tendency of wound area separation compared to the chevron incision.[10]


Ranjan MSICS Marker (RMM) (manufactured and marketed by EPSILON; USA) is designed to make topical flapless MSICS with higher astigmatic control a reality for beginners and mid-level cataract surgeons [Fig. 1a].

It is designed to help in three critical steps of MSICS through its three specific components:

  1. The 360° serrated edges at the base: It fixes the globe during tunnel making, obviating the need for optimal superior rectus bridle suture, obviating the want for peribulbar block, and putting up eye bandage after surgery [Fig. 1b].
  2. Tunnel marker: It helps create a perfect frown-shaped 6-mm incision, 2 mm away from the limbus. The measured location, size, and shape of the incision will help surgeons reproduce their results [Fig. 1c].
  3. Corneal axis marker: It helps in planning the incision on a steeper axis, taking care of pre-existing astigmatism.

Figure 1:
(a) The Ranjan MSICS marker. (b) Undersurface of the marker with 360° serrated edges. (c) Corneal axis marker with tunnel marker

It is important to understand that this tool has been made by keeping normal anatomical values of the eye in mind. The tool acts both like a pair of globe fixation forceps (eliminating the need for taking SR bridle suture) and a stencil (for creating the perfect size of the tunnel at the perfect place). No extra or additive pressure is applied on the globe while operating with RMM.

The functioning of RMM

The tunnel and corneal axis marker reduces post-surgery astigmatism by placing the least astigmatic incision in Koch’s astigmatic funnel on the steep angle, taking care of both pre-existing and surgically induced astigmatism.

The 0° and 180° meridian is marked with the use of bubble marker in the sitting position [Fig. 2a].

Figure 2:
(a) Bubble marking. (b) Marking of steep meridian with the corneal axis marker. (c) Using the tunnel marker as a stencil. (d) Stabilization of globe by the RMM during surgery

Using preoperative keratoscopic records (K1 and K2), the steep meridian of the affected person is identified. After draping is done, the corneal axis marker is then aligned with the pre-marked meridians on the patient’s cornea and steep meridian is marked [Fig. 2b].

The RMM is then circled to align the tunnel marker axis to the steep axis of the cornea. A perfect frown-shaped incision of 6 mm length and 2 mm away from the limbus is created using the tunnel marker as a stencil [Fig. 2c].

The tunnel is created with the aid of stabilizing the globe by mildly pressing the RMM on the globe; the serrated edges at the undersurface affords exceptional grip, thereby obviating the need for toothed forceps or superior rectus bridle suture [Fig. 2d].

The beauty of this tool is that no extended skill or long learning curve is required as this instrument is just a guide to make tunnel and simultaneously act as an enhanced globe fixation forceps.


The video explaining the use is available as a YouTube video titled “Ranjan MSICS Marker”.[11]

The flapless, topical MSICS is easily possible with the RMM as it reduces surgical procedure time, cost of the surgery, and hospital stay, and by this making blindness elimination more economical. The success depends to a great extent on the surgeon’s preference and experience, and proper patient selection, counseling, and preparation. It is a safe alternative to the use of retro- or peribulbar injections, is less time-consuming and definitely less costly which has a measurable impact in high-volume settings and at the national level.

If the patient is less than cooperative in the clinical examination area, this behavior may be worse in the operating room and such a person is not suited for topical MSICS. It is also important to avoid this method in “office squeezers”: patients who display a marked squeezing or muscular spasm during tonometry or indirect ophthalmoscopy. Young, anxious patients tend to fare worse with topical anesthesia as well. This method is also inappropriate in those who are markedly hard of hearing, are suffering from significant dementia, or are otherwise incommunicative. A wet lab is the fundamental ingredient of resident surgical training program as it provides a stress-free environment for the trainee to cultivarte their surgical skills. The RMM can also be used on human donor/animal (goat/pig)/artificial eyes to practice SICS before operating on a real patient. A multicenter study comparing post-surgical astigmatism in topical phacoemulsification surgery with monofocal intraocular lens implantation versus topical R-MSICS using RMM is underway.


RMM enables MSICS to be done under topical anesthesia with a potentially precise and safe incision and control over surgery induced astigmatism.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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11. Smart MSICS with Ranjan MSICS marker Available from: Last accessed 2022 Oct 12

Astigmatism-free MSICS; Ranjan marker; Ranjan MM; topical MSICS

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