How do I go about for a temporal SICS. I go for theis only on cases with a filtering bleb, or some problem with a superior SICS. Today I have done a sics in apatient with Post Trabeculectomy with a bleb. Ptient had very poor vision even before glaucoma surgery. She came a few days ago with a Leaking Margagnian Cataract with Sec.Glaucoma. After controlling the inflammation and IOP, I Have done the Temporal SICS today and ended up in a mess due to the constant Iris Prolape through the Frown Incision leadeng to capture of the nucleus, iris dilaysis, severe pigmnet dispersion etc.. For me the temporal sics has been a nightmare especially in complicated cases. Please guide me about the precautions to be taken.
It may be that you are finding temoral SICS difficult because:
1. Manouverability is difficult from the usual superior sitting position of the surgeon. You might benefit by changing your position.
2. You are doing temporal SICS only occasionally. Some surgeons are so used to temporal approach that they find superior rather difficult.
3.You are doing this in complicated cases, which would be difficult even with superior approach.
Some suggestions would be:
a) Frown incisions are unnecessory in temporal approach, because temporal approach doesn't induce much astigmatism. A straight or smile i.e. parallel to the limbus incision might be easier.
b) Stick to the basics to avoid iris prolapse, i.e. have adequate hypotony before starting to operate, take your tunnel well into the cornea, hydrodissection should be slow and do not inject too much visco under the iris plane.
c) Keep pushing the posterior lip,i.e. the floor of the tunnel with the vectis while withdrawing out the vectis.
Hope that helps,
Apart from the other factors listed I think the single most important factor to prevent iris prolapse during temporal SICS is to put a linear incision of about 7mm atleast 2mm away from the limbus.
Dr. Devaki senthilkumar
Dear Dr. Soundarajan
As you mentioned temporal SICS is difficult. If you try to deliver the nucleus by viscoexpression always leads to iris prolapse. If you try and use Phacosndwitch technique works better and prevents chances of iris prolapse. In my experience temporal SICS works better with assisted nucleus delivery than viscoexpression.
Dr. Sanjay Shah
Dear Dr Soundararajan,
As you mentioned temporal SICS is difficult as most of the surgeons perform surgical procedure sitting superiorly.
1. This problem is easier to solve by sitting on the temporal side of patient which will give better manouverability and more exposure and is more suitable particularly in operated glaucoma patients where trabeculectomy bleb is situated superiorly.
2. Making valvular incision will make it less susceptible for iris prolase.
3. Injecting more fluid during hydrodissection particularly with less valvular incision also increases chances of iris prolase.
Dr Jagat Ram., Professor,
Advanced Eye Centre, PGIMER,