Commentary: Protecting the protector

Manual small-incision cataract surgery (MSICS) is a more cost-effective and financially viable option for many settings in the developing world. Excellent effectiveness makes MSICS the most appropriate technique for performing high-volume cataract surgeries, especially in developing countries.^[1] Tabin et al. reported that cataract accounts for almost 75% of cases of avoidable blindness in developing countries. With a large amount of avoidable blindness due to cataract prevailing in our country and most of the population not being able to afford phacoemulsification, MSICS has become an important tool for eliminating it.^[2]

Learning the correct and safe technique of MSICS is of utmost importance to tackle the huge burden of cataract in our country. Endothelial protection during MSICS is critical to maintain the cornea transparent postoperatively. The authors of this review article have given nice tips as to how one can meticulously prevent endothelial cell loss during each step of MSICS surgery.

Handling the instruments that are introduced in the anterior chamber is a continuous learning process, so all surgeons at every level of their career should emphasize on improving one’s own technique.^[3] The surgical techniques in cataract surgery are evolving toward a safer side in terms of endothelial protection, so one should not hesitate in adapting a new and safer technique.

The most common step where the endothelium gets damaged is during nucleus delivery.^[4] There are various methods of nucleus delivery. The surgeon should practice that method which is safe in his/her hands.

Nowadays various types of cohesive and dispersive ophthalmic viscosurgical devices (OVDs) are produced in our country and they are available at an affordable cost. Appropriate OVDs should be used depending on the type of cataract and associated ocular problems, especially during nucleus delivery and intraocular lens (IOL) implantation. Authors of this review article have mentioned different techniques of use of these OVDs to safe guard the endothelium.

Maintaining the anterior chamber all through the surgery is important to minimize the endothelial cell loss in MSICS. Though MSICS has valved and self-sealing incision to maintain the depth of the anterior chamber, the chamber depth may alter during instrumentation and nucleus delivery. So one should take care to maintain the depth of the anterior chamber with the appropriate use of irrigating solutions, OVDs, the correct method of introducing the instruments into the anterior chamber, and proper use of Simcoe cannula.^[5] One should also be aware of patient-related factors that alter the depth of the anterior chamber like lid squeezing and positive pressure in obese patients.

One should know the safer dose and right technique of using various intraocular drugs because the toxic effect of these drugs on the endothelium can sometimes remain permanent.^[6] There is also a need for standardizing the quality of the drugs at the production level; hence, the appropriate authorities should make stringent rules and monitor the drugs produced by various companies in our country.