Small Incision Cataract Surgery (SICS)

Small Incision Cataract Surgery (SICS) is a refined, manual extracapsular cataract extraction (ECCE) technique that uses a self-sealing sclerocorneal tunnel incision (typically 5–7 mm) to remove the cataract and implant an intraocular lens (IOL). It is a cost-effective alternative to phacoemulsification, especially in resource-limited settings where advanced equipment is unavailable.

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Key Features of SICS

1. Incision:

   • Location: Sclera or limbus (unlike ECCE’s larger corneal incision).

   • Size: 5–7 mm (smaller than ECCE’s 8–10 mm, but larger than phaco’s 2–3 mm).

   • Design:

     • Triplanar self-sealing tunnel (prevents leakage without sutures).

     • Blunt dissection into the anterior chamber.

2. Anterior Capsulotomy:

   • Continuous curvilinear capsulorhexis (CCC) (preferred) or can-opener technique.

3. Nucleus Delivery:

   • Hydrodissection to free the nucleus.

   • Manual expression using a wire vectis or fishhook technique (no ultrasound).

   • Sandwich technique (using irrigating vectis and a sinskey hook).

4. Cortex Removal:

   • Manual irrigation and aspiration (I/A) to clean the capsular bag.

5. IOL Implantation:

   • Rigid or foldable PCIOL (posterior chamber intraocular lens) placed in the capsular bag.

   • If the posterior capsule is compromised, an anterior chamber IOL (ACIOL) or scleral-fixated IOL may be used.

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Advantages of SICS Over Conventional ECCE

✔ Smaller incision → less astigmatism and faster recovery than ECCE.
✔ Self-sealing wound → no sutures needed (unlike ECCE).
✔ Lower cost than phacoemulsification (no expensive phaco machine required).
✔ Effective for hard cataracts (where phaco may struggle).
✔ Shorter learning curve for surgeons compared to phaco.

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Disadvantages of SICS (Compared to Phacoemulsification)

✖ Larger incision than phaco → slightly higher induced astigmatism.
✖ Manual nucleus removal → higher risk of capsular rupture in inexperienced hands.
✖ Slower visual recovery than phaco (but faster than ECCE).

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Indications for SICS

• Mature/hard cataracts (brunescent, black cataract).

• Low-resource settings (where phaco machines are unavailable).

• Pseudoexfoliation syndrome (weak zonules may make phaco risky).

• Corneal opacity (where phaco visualization is difficult).

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Comparison: SICS vs. Phacoemulsification vs. ECCE

Feature	SICS	Phacoemulsification	Conventional ECCE
Incision Size	5–7 mm (tunnel)	2–3 mm (clear cornea)	8–10 mm (sutured)
Wound Closure	Self-sealing	Self-sealing	Sutures required
Nucleus Removal	Manual expression	Ultrasound breakup	Manual expression
Cost	Low	High	Low
Recovery Time	Moderate (1–2 weeks)	Fast (few days)	Slow (weeks)
Astigmatism	Moderate	Minimal	High
Best For	Hard cataracts, resource-limited settings	Most modern cases	Rarely used today

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Postoperative Care & Complications

• Topical antibiotics & steroids (to prevent infection & inflammation).

• Watch for:

  • Posterior capsule opacification (PCO) (common, treated with YAG laser).

  • Cystoid macular edema (CME).

  • Endophthalmitis (rare but serious).

  • Wound leak (if tunnel construction is poor).

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Conclusion

SICS is an efficient, low-cost alternative to phacoemulsification, particularly valuable in developing countries and for dense cataracts. While phaco remains the gold standard, SICS provides excellent outcomes with minimal equipment, making it a crucial technique in global cataract blindness eradication programs.