Address: Ground Floor, Dream 21 Building, 21st street (behind Jollibee Riverside, Beside Bob’s Resto). Bacolod City Negros Occidental.

Tel. number:  434 0240.

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This is my fiesty 90 y/o patient, whose cataracts I did 2 years ago, using MSICs w/Lens implants…she was severely handicapped with poor eyesight prior to the surgery…

After the operation, she regained her sight (20/30 OU) and also her overall health improved….she also became very independent, often leaving her house alone to walk around town….

Recently, she developed SECONDARY CATARACT, a condition common in about 30 per cent of all modern eye cataract surgery…it is a thickening of a membrane behind the lens implant…

The ONLY way to safely deal with this disease is to use the YAG LASER…and laser open an opening thru which the patient can see again…

Fortunately, our clinic has the most advanced YAG LASER in the market…the CARL ZEISS VISULAS 111 YAG LASER….

…The problem is solved in 2-4 minutes….

Sarabia Optical has survived all these years from 1906 to 2012 and is stil growing. Dr. Miguel Sarabia think that their grandfather Dr. Federico Sarabia was the one who established the Philippine College of of Optometry which was the very first school teaching the science. Iit was later sold to Centro Escolar University and is still producing Optometrists to this day.

It is an old family story that when he did that, many of his fellow optometrist ( mainly Spaniards trained in Europe) asked him “Why? Are you crazy? It wil produce competition to us!” and his response was…”The Philippines is a young growing country, we need more optometrists to serve our people…and besides, my graduates will not be my competitors…I will HIRE them for the branches of Sarabia Optical!”

I guess that is how the Sarabia Optical became the largest family owned optical chain in the Philippines…

This is a unique story of two guys who never ever met each other until today.  Mr. Ambaugh is from Boston and Mr. Grayson from Australia.  Grayson was looking for a cataract surgeon in the internet and Mr. Ambaugh recommended me since I successfully operated both his eyes…

Here are our pictures when they meet on Sarabia Eye Clinic.

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Some may wonder why I’ve spent my Labor Day weekend time revising and republishing some former articles on Cataract Surgery here in the Philippines. The answer is simple. A new reader got in touch and explained a very interesting new procedure for curing cataracts via surgery that seemed just too good not to know about. In response to some of my questions, he very generously offered to write us an article about the new procedure, one of his specialties. So without further ado, I present Doctor Miguel Sarabia, an ophthalmologist practicing in Bacolod City, here in the Philippines.

MSICS…Manual Small Incision Cataract Surgery, an Alternative to Phaco.

In the ophthalmology world today, modern cataract surgery is often associated with Phacoemulsification, a high technology procedure using ultrasonic machine to pulverize cataracts thru micro-incisions, after which lens implants are placed inside the eye, most often now with high-tech injector devices.

This type of cataract surgery has been around since the 1990’s and has now evolved into its current state of extremely advanced machines, micro-incisions and amazing multifocal lens implants.

All of these advancements are fabulous for the patient if not for one problem…the price. A state-of-the-art phaco machine now costs about $ 100,000.00 US. This has to be matched with a very good operating microscope costing around the same price. Plus the new machines demand that you use single use cassettes, tubing, and disposable knives, gels etc.

Nowadays, there are also “premium” intraocular lenses, with highly sophisticated optics…and very steep prices….Guess who ends up footing the bill?

Today, in the Philippines, a phaco eye surgery with premium IOL in a class A eye center will set you back at least P 100,000.00 (about $2400 USD at today’s rates) per eye. That’s 200k for both eyes. A lot of money for a retired senior citizen.

So, you may now be asking the question that all my patients ask me….is there a cheaper way to have a good quality eye operation? I asked myself the same question 10 years ago, after I had been doing phacoemulsification of my patients for about 2 years….

Cataract Surgery — MSICS

I did not realize at that time that in order to answer that question I had to personally travel thousands of miles….toINDIA. This is where I witnesses my first Msics surgeries, and that experience has changed my practice of eye surgery forever.

At that time, in year 2000, most of us eye doctors thought that there was no other way to do small incision cataract surgery except thru phacoemulsification. The other alternative was to open the eye at least 2.5 cm, deliver the lens and implant the IOL, after which, it took 5 or six sutures to close the wound. This was my mindset until one day I received a call from my old mentor Dr. Steven Waller , chairman of the USAF department of ophthalmology… he told me that a new system of cataract extraction thru small incision was developed by the doctors of Aravind Eye Hospital, using only manual instruments.

He believed that this was a great technique for doctors practicing in countries where a lot of poor people were blind from cataract. It was very fast, economical and produced almost the same results as patients who underwent phacoemulsification, since it was also a small incision, sutureless technique.

If you watch a video of phacoemulsification and msics, you will note that the initial portion of both operations are essentially the same…an incision into the anterior chamber of the eye . With phaco it is usually a 3mm clear cornea incision. In Msics, it is a 6 mm triplanar incision in the sclera, creating a tunnel into the anterior chamber of the eye. Then, opening of the anterior capsule of the lens with a CCC or continuous curvilinear capsulorhexis…this is a fancy term for a complete circular cut on the anterior capsule of the lens.

Then there is hydrodissection of the nucleus with water, cleaving and separating it from the capsular bag. Both msics and phaco employ this step. The next step is the removal of the nucleus. With phaco, the nucleus is pulverized by the ultrasonic phaco needle, then vacuumed out of the eye.

With MSICS, the nucleus is delivered out of the eye with a spoon-like device…the irrigating vectus. This is actually the only difference between the two techniques.

After the nucleus is removed, both phaco and msics employ irrigation and aspiration devices to clean out the residual cortical material. The last step in both techniques is the same…the implantation of the intraocular lens.

In phaco, foldable lenses are employed because the incision size is only 3 mm in size. In Msics, the lenses used can be rigid lenses because the incision size is usually 5.5 to 6.0 mm which can accommodate a rigid lens.

So what is the difference in performance of foldable lenses vs. rigid lenses? None, actually. They both give good vision to patients.

Many studies now published in the internet comparing the results of Phaco and Msics have the same conclusion…there is no significant difference in the results of both procedures…except… The Cost.

MSICS only costs about P15,000.00 while Phaco would cost around P40-50,000.00.

Cataract Surgery — Is MSICS Any Good?

MSICS in my opinion, is also the safer technique when doing very dense, rock hard or hypermature cataracts. This type of cataracts give problems when using phacoemulsification. Many cases of the cataract falling into the eye have occurred when doing phaco on very hard cataracts. ( just look up “dropped nucleus cataract” in youtube.).

So, now you know the secret of Aravind EyeHospital…Msics. How did I learn Msics? I traveled to Aravind Hospitalin 2001 and trained under the great Dr. Venkatesh, the Msics master of Aravind.

Aravind Hospital is very unique in this world because its primary goal is to provide the best eye surgery to the most number of poor or indigent people inIndia. MSICS is the product of their intensive research to find a cataract technique that could produce similar visual results as PHACO, but at a very much reduced price. So today, about 20,000 cataract surgeries are performed atAravindEyeHospitalsystem…about 80% are MSICS. By the way, the WHO has now recognized Msics as their cataract technique of choice in all U.N. WHO EYE MISSIONS. (www.aravind.org)

By Dr. Miguel Tomas S. Sarabia

Diplomate Philippine Academy of Ophthalmology

Alumni of LAICOAravindEyeHospital,

Community Ophthalmology and MSICS Course.

www.sarabiavision.com

http://www.youtube.com/watch?v=Ir9OYWgmWwQ

This Manual Small Incision Cataract Surgery procedure is under topical anesthesia, no injections…

How long was that frown incision?

Its about 7mm, base your frown length on the hardness of the cataract…a large soft cataract can be delivered thru a 5.5 mm while a hard yellow brown cataract must have an extended frown…you will know how long thru some experience. The edges of soft cataracts are usually whitish,fluffy, and as you rotate the nucleus out of the bag, the nuclear material crumbles, while hard cataracts have a more solid texture and are in fact easier to subluxate to the anterior chamber

Is the irrigating vectis connected to a syringe or to macroset connected to an irrigating bottle?

The manual irrigating vectus has one port…attached to a 5 cc syringe..with about 3 cc fluid inside…slip the vectis under the nucleus WITHOUT infusing any fluid…then as you deliver the nucleus…gently! squirt increment amounts of bss into the chamber…also…counter tracti­on at 6:00 is crucial if you are doing it under retrobulbar anesthesia…if under topical…simply tell the patient to look downwards as you are delivering…Look for my articles in OSN Supersite..

– Dr. Miguel Sarabia

http://www.youtube.com/watch?v=tb9f5Z8AV3k

Dr. Miguel Sarabia of SarabiaVision.com personally received his Manual Sutureless Cataract Surgery or MSICS training from Dr. Venkatesh at Aravind Eye Hospital in 2001.

In this Video Dr. Venkatesh from Aravind Eye Hospitals performs 2 unedited, back-to-back Manual Sutureless Cataract surgeries. This technique is state of the art for high volume, high quality cataract surgery in developing countries.

http://www.youtube.com/watch?v=Sd0iGSB0eXs

Despite all that modern technology has done to advance the treatment of cataracts, our greatest challenge continues to be the large and increasing backlog of cataract blindness in developing countries.1–5 While in North America and western Europe, intraocular lens (IOL) research and development are primarily directed towards reversing lens ageing (presbyopia), millions in developing nations with reversible blindness caused by cataracts go untreated.

Modern phacoemulsification machines are expensive to purchase and maintain, have relatively high disposable costs, and require extensive surgical training. Furthermore, for the more advanced and mature cataracts typical of underserved populations, performing phacoemulsification becomes more difficult and complication prone. What is needed is a high volume, cost effective, low technology procedure that can treat the most advanced of cataracts with a low complication rate in the shortest amount of time.

This very goal is being achieved in a handful of international programmes that are providing a hopeful paradigm for overcoming worldwide cataract blindness. I have had the privilege of visiting both the Aravind Eye Hospital network in southern India, and the Tilganga Eye Centre in Kathmandu, Nepal. Seeing first hand how their systems provide high volume, low cost cataract surgery is an awe inspiring experience for any visiting ophthalmologist.

Founded in 1976 by the now 87 year old Dr G Venkataswamy, Aravind Eye Hospital has grown into a network of five regional eye hospitals providing high level ophthalmic care to the poor population of southern India. Private paying patients comprise approximately 30% of their patient base. This revenue funds 70% of their services that are provided at no cost to the indigent via a financially self sustaining programme that receives minimal government reimbursement. In terms of cataract surgery, this means that of the approximately 200 000 procedures performed annually in the Aravind system, 70% are provided free.

While private cataract patients at Aravind may pay anywhere from $200–$300 to undergo phacoemulsification with foldable IOLs imported from the United States, the non-paying cataract patients are treated for less than $15 per case, including the IOL. This is accomplished by performing a manual, sutureless, small incision extracapsular procedure with re-usable equipment and supplies.6–9 Their IOL manufacturing facility, Aurolab, produces poly(methlymethacrylate) (PMMA) IOLs for less than $5 per lens. Following a retrobulbar block, the nucleus is expressed through a capsulorhexis and a temporal, self sealing 6.0–6.5 mm scleral pocket incision. Manual cortical cleanup precedes capsular bag implantation of a PMMA IOL. The technique is commonly abbreviated as manual SICS (small incision cataract surgery).

“An efficient, high volume system utilising low cost, sub-5 minute procedures to tackle advanced cataracts with minimal complications is clearly the best way to use the scarcest and most precious asset of the system—the cataract surgeon”

While the procedure itself seems straightforward, it is the stunning speed, skill, and efficiency with which it is performed that must literally be seen to be believed. By alternating between two parallel operating room tables, a single surgeon is able to perform over 15 cases per hour by consistently completing sub-5 minute procedures on the densest of cataracts with no intervening turnover time. To ensure efficiency across different surgical teams, every aspect of the procedure is standardised, from preoperative patient and instrument preparation to the surgical steps themselves. Having been screened in outlying eye camps, as many as 300–400 cataract patients will by bussed to an Aravind eye hospital where they will all undergo their surgery on a single day. After several days of in-house follow up, they are transported back to their rural villages where a local postoperative visit and refraction are performed 1 month later by the Aravind staff. This standardised Aravind system streamlines and centralises cataract care by performing all surgery in the main hospital.10

Founded in 1994 by Dr Sanduk Ruit, the Tilganga Eye Centre is a shining example of an efficient eye care delivery system on a smaller scale. Dr Ruit has developed his own variation of the manual, sutureless SICS.11–13 Tilganga Eye Centre is also financially self sustaining wherein private care subsidises charity care. They also have their own IOL manufacturing facility, which, like that at Aravind, is able to supply low cost IOLs to other developing countries. Because the rural population in Nepal is so widely scattered among mountain villages that are accessible only by foot, the Tilganga system strives to deliver portable cataract care by transporting the necessary staff and equipment to remote eye camps.14,15 Using a single portable operating table, the Tilganga surgeons can also perform more than 10 cataract surgeries per hour. As at Aravind, the high volume, cost effective Tilganga surgical techniques and protocols are standardised across their surgical teams.

Though of a different scale and serving different types of communities, Aravind and Tilganga are complementary models of how best to address the world’s backlog of cataract blindness. They demonstrate that the solution requires not just a cost effective surgical technique, but also an entire system of efficient and financially self sustaining cataract care delivery. There must be a system for attracting, screening, diagnosing, and transporting cataract patients to and from rural camps. There must be a source of low cost IOLs, medications, and supplies. Most importantly, there must be highly coordinated teams of dedicated ophthalmologists and support staff, who execute their roles with military precision. To assure maximum efficiency and reproducibility, there must be a standard protocol for every aspect of care.

In this issue of BJO (p 1079), Venkatesh and co-authors provide a detailed outcome study of the high volume, manual SICS (small incision cataract surgery) method used at Aravind. Two days’ surgical volume for three cataract surgeons (~600 cases) were randomly selected and reviewed retrospectively. Despite a high percentage of advanced and mature cataracts, operative complications were extremely low, and vitreous loss occurred in less than 1% of cases. Understandably, stringent postoperative outcome data with long term follow up are not easily attainable in a rural cataract camp population. However, with 6 week follow up of nearly 90% of the patients, 95% achieved a best corrected visual acuity of at least 6/18 (not excluding macular or other pathology). These outcomes are all the more impressive considering that almost 90% of the patients had preoperative vision of 5/60 or worse, and that the surgical time for these nearly 600 patients averaged 3.75 minutes.

How does the manual, sutureless SICS compare to other cataract methods? One prospective randomised study determined that this technique resulted in better uncorrected acuity than standard extracapsular cataract extraction.16 Astigmatism control is particularly important in populations that have limited access to spectacles. I recently participated in a prospective randomised trial at the Tilganga Eye Centre comparing manual, sutureless SICS with phaco in a cataract camp population. While the data analysis is not complete, I can attest to the difficulty of performing phaco in a camp setting with a high incidence of advanced cataracts and poor corneal visibility. Finally, from the standpoint of cost effectiveness, manual SICS is clearly superior to the alternatives.17,18

Outcome studies such as these provide convincing evidence that surgical systems, such as those at Aravind and Tilganga, are the most promising, efficacious, and cost effective means to eradicate cataract blindness in developing countries. Beyond the impressive productivity of these two institutions, equally important has been their desire and ability to train surgical teams from other developing countries in their methods of cataract surgery. An efficient, high volume system utilising low cost, sub-5 minute procedures to tackle advanced cataracts with minimal complications is clearly the best way to use the scarcest and most precious asset of the system—the cataract surgeon.
Note in Proof

From the standpoint of cost effectiveness manual small incision cataract surgery is clearly superior to the alternatives

Author: DF Chang
Correspondence to: D F Chang University of California, San Francisco, Los Altos, CA 94024, USA; dceye@earthlink.net

source: http://bjo.bmj.com/content/89/9/1073.full

The iSert™ Preloaded Injectable Intraocular Lens System is a proven technology. In use in Europe and Japan since 2007, and now avaialble in Bacolod City at Sarabia Eye Specialists Clinic, the iSert™ Preloaded System’s completely closed system—from manufacturing facility to implantation in the eye—delivers a lens that is untouched by human hands for the ultimate in safety and sterility. The single-use inserter eliminates the risk of contamination from endotoxins associated with reusable materials and weaknesses of flash sterilization that can result in toxic anterior segment syndrome (TASS).

In addition, doctors can utilize the glistening-free, hydrophobic acrylic aspheric Hoya Surgical Optics lenses introduced earlier this year with the advanced technology of the iSert™ Preloaded IOL System. The iSert™ bevel tip is designed to accommodate surgeons who prefer incisions smaller than 2.4-mm.

For more information about this advance eye implantation technology contact us at (034) 434-0757 or email us here.

http://www.youtube.com/watch?v=bxUzxAzXn1g