Step-by-step Overview

Learn about all of the 26 steps in the MSICS VR Simulation

Dive into the heart of the MSICS Simulation with this concise 26-step overview. Uncover what each step entails, understand the expected outcomes, and become aware of potential adverse events (AEs) for the interactive steps.

You can also review this information in VR via "Procedure Overview" in the main VR lobby.

Safety Check In

Welcome to the Orbis MSICS simulation!

The surgical instruments will be on the Mayo stand to the right and the saline irrigation bag on the left. In this step, familiarize yourself with the handpieces, help button and available guidance tools.

You will then proceed to the Surgical Safety Check-In during which you will review the patient information and select the appropriate intraocular lens (IOL) power.

Microscope Alignment

In this step, adjust the height of the microscope and test its positioning to ensure you are relaxed and comfortable.

Patient Preparation

In this step, you will confirm the patient, the procedure, and completion of the sterile prep.

Patient identification has been checked and operative eye confirmed. In this case, you will be performing MSICS on a mature cataract in the right eye. The eyelid speculum has been positioned and the pupil has been dilated.

Conjunctival Peritomy

In this step, you will observe a conjunctival peritomy using Westcott scissors and Bonn forceps. The conjunctiva and Tenon's capsule will be dissected from the superior limbus using blunt and sharp dissection to expose the sclera.

Caution should be taken to not take the Tenon’s off too aggressively as this could shred the scleral fibres. Additionally, it is possible to over-cauterize and create conjunctival edges, which can shrink the conjunctiva and make it difficult to reposition at the end of the case.

Paracentesis

In this step, you will create a side port by performing a paracentesis using the paracentesis blade and Bonn forceps.

It is essential that the paracentesis blade is parallel to the iris. Avoid accidental contact with the iris, lens or anywhere else in the sclera during paracentesis.

Preparing the AC: Injecting Air Bubble

Preparation of the anterior chamber (AC) is a three-stage process to stain the anterior capsule of the lens to make performing the continuous curvilinear capsulorhexis (CCC) easier.

The diameter of the bubble should be the same diameter as the pupil. Damage is possible if the injection is stopped when the diameter of the bubble is less than 80% of the pupil diameter.

Preparing the AC: Injecting Trypan Blue

In this second AC preparation step, you will stain the anterior capsule by injecting Trypan blue.

The blue dye should evenly disperse in the AC. Corneal damage is possible if the injection is continued after reaching the end fill point.

Preparing the AC: Injecting OVD

In this third AC preparation step, you will remove the air and Trypan blue and stabilize the AC by injecting Ophthalmic Viscosurgical Devices (OVD).

The OVD should replace all dye and air. Stop when all dye and air have been replaced by OVD. Overfilling of AC can damage zonules. Corneal damage may result from residual dye remaining in AC.

Marking the Scleral Incision

In this step, you will create incisional landmarks by marking the sclera using callipers and Bonn forceps.

The tips of the callipers should be aligned 3.5 mm from the limbus. Inaccurate marking (>1 mm from optimum positioning) may result in poor scleral tunnel orientation.

Scleral Incision

In this step, you will create a half thickness scleral groove using the paracentesis blade and the Bonn forceps.

The groove should be made in one continuous motion with gentle force. Excessive pressure can lead to scleral perforation.

Sclerocorneal Tunnel

In this step, you will dissect a half-thickness scleral tunnel using a crescent blade and the Bonn forceps.

The long and the short axis of the crescent blade should be parallel to the scleral wall. Poor alignment can lead to inner or outer tunnel wall damage. Avoid excessive cutting force which leads to loss of control.

AC Entry

In this step, you will first create the inner tunnel opening with the keratome and the Bonn forceps.

Full extension of the inner opening is critical for safe nucleus delivery. The blade tip should not contact the lens capsule or iris.

Continuous Curvilinear Capsulorhexis

You will first observe injection of OVD into the AC to prepare for CCC. OVD injection is critical for safe and efficient execution of the capsulorhexis.

You will then interactively create a controlled circular opening in the AC using the cystotome to tear the capsule.

Tearing towards the pupillary margin risks compromising capsular integrity. Excessive downward force against the lens increases the risk for zonular breaks.

Hydrodissection

In this step, you will observe the release of the nucleus from the capsular bag and cortex using saline injected from the 27 gauge cannula.

Caution should be taken to not apply excessive downward force on top of the nucleus with the cannula. Ensure that the tip of the cannula is placed just under the edge of the capsular bag.

Rotation of the Nucleus

In this step, you will cleave all cortical attachment to the nucleus.

Continue rotation until the nucleus rotates freely (approximately 180 degrees). Excessive downward force (<30 gms) can cause capsular rupture. Avoid endothelial contact.

Nucleus Prolapse

In this step, you will observe the lens nucleus being prolapsed into the AC in preparation for removal. Inject adequate amount of viscoelastic material to push the nucleus up through the anterior capsular opening. It is essential that the tip of the cannula is in the capsular bag but be careful to avoid puncturing the posterior capsule.

Nucleus Delivery

In this step, you will remove the nucleus using the Vectis loop and Bonn forceps. The lens loop acts as a guide for the nucleus through the tunnel.

It is critical to not snag and drag the iris out with the nucleus (i.e., iridodialysis risk). Excessive force can easily break the posterior capsule resulting in vitreous loss.

Cortex Removal

In this step, you will remove all remaining cortical tissue from the capsular bag using the Simcoe cannula.

The aspiration port should be facing up and be in contact with the cortical material before aspiration is applied. Contact with the lens capsule can cause rupture. Contact with the iris or the pupillary margin can cause iris damage.

IOL Insertion

In this step, you first select the correct IOL power for the patient based on preoperative measurements. You will then observe OVD injection used to protect the AC structures and maintain the capsular bag during IOL insertion.

Finally, you will insert the leading haptic of the IOL into the capsular bag using the lens insertion forceps and Bonn forceps. You must avoid damaging the iris, cornea, and posterior capsule while positioning the haptic.

IOL Dialling and Implantation

In this step, you will complete IOL insertion by positioning the trailing haptic in the capsular bag.

Excessive downward or radial force can cause zonular or capsular damage resulting in IOL dislocation or vitreous loss.

Inspection of the Wound

In this step, you will observe the main scleral incision being tested to ensure it is not leaking.

Failure to adequately check the wound and resolve any leaks can lead to postoperative hypotony or even endophthalmitis.

Closure of the Conjunctiva

In this step, you will observe the conjunctiva being repositioned and re-attached with the Semkin Bipolar cauterizing forceps.

Failure to adequately position the conjunctiva can lead to significant postoperative discomfort, epithelial ingrowth into the tunnel, and endophthalmitis.

Final Patient Preparation

In this step, you will observe the eye pressure check and the eye being flushed of debris. Once this is complete, the eye is stable and ready for patching.

Failure to remove debris and check the intraocular pressure (IOP) can lead to infection or wound instability.

Surgical Safety Check Out

In this step, you will be asked to complete a Surgical Safety Check-Out to ensure the patient is stable and the eye is properly dressed for discharge.

A good patient experience requires attention to all the details of postoperative management

Watch the video for a full playthrough of the Orbis MSICS VR experience!

Note: The microscope alignment feature has been updated. The process demonstrated between 00:31 and 00:52 is no longer applicable. However, all other parts of the video remain accurate.

Thank you for completing this overview. If you have any questions, please contact your training course supervisor.

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