Friday, May 13, 2016

My Experience with Manual Small Incision Cataract Surgery (MSICS or SICS) Training at Arasan Eye Hospital, Erode India

Two surgeons being trained simultaneously at Arasan Eye Hospital -- one in SICS, the other in phaco.  The instructor monitors the cases in progress.
I'm currently finishing two weeks of training in manual small incision cataract surgery (MSICS or SICS) at Arasan Eye Hospital, in Erode, Tamil Nadu, India, and thought it would be useful to share my experience.  It was a very positive experience.  Before I came I had difficulty finding out much detailed information about the training or the experience, so I hope this is helpful to you.

Surgical Background

Many of the ophthalmologists who come to Arasan to learn MSICS or phaco, often with limited experience with the procedure.  I think that the experience you bring with you to the training affects your experience and the speed at which you gain mastery.

In my case, during my residency at Northwestern in Chicago in the early 1990's we were trained in ECCE and phako with a superior tunnel incision.  There were no foldable lenses widely available yet.  After my residency I headed out to the Pacific because of my interest to serve in an underserved area.  I was for a year at the LBJ Tropical Medical Center in Pago Pago, where because of limited technology, I did ECCE with manual Simcoe I/A.

During the ensuing 5 years, I was at the Commonwealth Health Center on the island of Saipan, in the Mariana Islands.  There I continued with ECCE with manual Simcoe I/A.  At that time, the Blumenthal mini-nuc emerged, and I tried this technique a few times, but wasn't able to master it.

Eventually, I opened my own practice, acquired a phaco machine, and went back to phaco with a superior tunnel, but quickly transitioned to temporal clear cornea with a foldable lens through a 2.75 mm incision and topical anesthesia.

So, that's my background and skill level I brought with me.  I had experience with every step of the procedure except for prolapse of the nucleus into the anterior chamber.  But, it had been years since I have done the other important steps of the procedure.  I hadn't made a scleral tunnel or put in anything other than a foldable IOL for at least 10 years.


My goal in getting training in SICS was to be able to take several trips a year to underserved areas for volunteer work.  I have done surgical expeditions in the past with SEE International, however, they now require all their surgeons to have SICS training, as that is the primary procedure being used in most eye camps.  So, that's what motivated me to spend two weeks here learning SICS.

Why Arasan?

For some time I tried to set up "in the field" training with SEE International, but it just didn't work out.  Although I am American, I am living in Europe now, and while SEE offers wet-lab training in MSICS in the US once or twice a year, it was too far to travel simply for a weekend of wet-labs.  I did a bit of research, and there are quite a few hands on training programs in India, but most of them are a month or longer in duration.  Arasan, however, provided a 2 week training program in MSICS.  That was doable for me.  I emailed Arasan, and got initial information from Anitha, who manages the doctors who visit.  I wanted to talk to some of the other people who had done the training, and Anitha sent me the emails of all the doctors who had been here over the past year.  Everyone I heard from was generally positive, so I decided it would be a good way to get training.


At Arasan, the cost of all their training programs are on a "per case" basis, and they guarantee you that number of cases during your time here.  If you want additional cases than the minimum amount, there are additional charges.  The prices fluctuate from year to year, and I think are adjusted somewhat according to country of origin, or level of training.  Information is available through contacting Arasan.  In my situation, a US trained experienced ophthalmologist, seeking MSICS training in 2016, the price for 30 MSICS cases was $2,500, with additional cases at $100 per case.  While I was here, there was also a physician here from Germany who had no surgical experience (apparently in Germany, you complete your residency without any intraocular surgical experience) who was here for two weeks of SICS training, and three weeks of phaco training.  There was also an ophthalmologist here from Jordan who had come for one month of PPV training.  The costs of phaco is higher than for SICS, and the cost of PPV higher still.  They were both very happy with their experience here, and felt it was a very good value, as did I.  The course fee needs to be transferred to Arasan to confirm your participation ahead of your arrival.  It actually goes to Arasan's charitable branch, Save Sight Foundation.  Contact Arasan for the costs for your situation.

This cost does not include lodging, food, airport transport, medical license, etc. It's just for the training.

Medical License and Visa

Anitha will hook you up with an application for a temporary medical license.  Arasan will front the cost, and you'll repay once you arrive.  It does take a few months to get it though, so you need to plan ahead.

There seems to me one official, and one unofficial route to get a visa.  Officially, Anitha told me I had to get a student visa, which required that I go to the Indian Embassy and apply in person. That was a pain, but I did it.  Unofficially, you can do the training on a 30 day tourist visa, which you can apply for online, at much less expense.  One of the doctors while I was here had come in on a tourist visa.  He had put is address as "Arasan Eye Hospital", and when he was coming in, they asked him what kind of tourism he was doing there, but he got through.

What to Bring

You don't need to bring any surgical instruments.  You don't need to bring scrubs or lab coats (even though they tell you to bring two -- I did and never wore them, nor did anyone else).  You don't need to bring formal clothes.  You just need cool "business casual" clothes -- khakis or pressed pants, with polo shirts or short-sleeve button-down shirts.  That's how most of the people in India are dressed, as are all the doctors at the hospital.  The women, of course, wear sari's or kurti's, which you can buy here, but it's not really expected.  Most people in Erode wear sandals.  Because I was walking in the streets, I felt more comfortable wearing casual close-toed shoes.  In the OR, you'll wear slippers that are provided.  No one wears short pants despite the heat.  I brought a couple of pair, and wore them in the apartment.

If you're from a country that uses toilet paper, bring a role.  If you're staying in the guest house, let Anitha know you'll need some and she'll send someone out to get it.  It's not easy to find in the small shops that line the walk to the hospital.

If you have an interesting case to present, bring the presentation with you.  On Wednesday mornings, there is no surgery, but instead is a case conference at 9 AM.  It's nice to participate in, and they welcome a presentation of 10-15 minutes -- either a case, or a topic of interest.  Throw in some slides of your home country or your practice, as it makes it more interesting.  After the conference, everyone has breakfast together on the second floor.


Although the surgical experience, and operating room mentorship was excellent, I think Arasan fell a bit short in helping you prepare to get the most out of your training.  I took the initiative to download Aravind Eye Hospital's free SICS book, which is quite good, but it is "the Aravind way", not the Arasan way of doing the surgery.  I also spent a lot of time watching videos online of MSICS to get a sense of the procedure.  However, I think that the program would be strengthened if they recommended some reading themselves, and more importantly, had their own surgical videos online so that you could be better prepared to have a knowledgeable start once you got here.  For a teaching center, it has very few online surgical videos.  Although this was not so critical in my case, I imagine that for those learning phaco or PPV, it would be most useful to be given some recommendation of books to read, as well as surgical videos to review prior to arrival.  The better prepared you are, the more you'll get out of the training.


Initially I was told it was a 15-day training course, running from a Monday, through a Tuesday.  I thought it was odd, as I would have preferred to not have to stay around for another weekend, but I thought it was a set program.  As it turns out, it's really not.  You can tell them how much time you have, and they will work to get the minimum number of cases to you in that time.  In my case, a special election was called, which meant that there would be no surgery during the final Monday and Tuesday, so the hospital worked to get me the 30 cases within a 12 day period.  Now, the ability to accomplish this may test your abilities.  In my case, I did the 30 cases within six OR days.  My case load per day went like this: 2, 3, 3, 5, 8, 9.  Those last two days were a killer.  So, don't be in a hurry.

It's nice to work out some of these details of how many cases to expect per day, and how many days you can stay, before your arrival.  After I arrived, I had to change my tickets because of the election.  If I had known of the possibility of having a trip of two-weeks duration, I would have planned accordingly, and avoided the extra cost of changing my flight.    Now, as it turns out, I finished my 30 cases on a Tuesday, with a new ticket to leave on the coming Saturday.  Anitha said that I could operate on a "regular" schedule of 3 cases per day for the remainder of the time, but if I wanted more than that, I'd have to pay the additional $100 per case.  I asked for 5 cases per day, and pointed out that I had spent $400 to change my tickets because of the election, and Arasan graciously agreed to give me 5 cases per day for each of my last two OR days, instead of 3, at no extra cost.  By the end of my time here, I had completed 40 SICS cases, which is higher than the average 30 cases.


Coimbatore is the nearest major airport, about 100 km away.  Anitha arranged for a driver to pick me up.  It was about a 1.5 hour drive to Erode.  I arrived in Erode in the early afternoon.  We stopped by the hospital to say hello, and to meet the chairman, Dr. Paneer Selvam.  Anitha collected the money I owed for the medical license, and the transportation, as well as the stay in the guest house.  I asked Anitha ahead of time how much it would all come out to, so that I could bring enough cash with me. They accept USD and EUR for this payment.  I asked about where to exchange currency and the hospital's accounting office exchanged some money for me just so that I'd have some cash over the weekend.  The exchange was 5% less than the published rate online, which is pretty typical for currency exchanges.

One thing worth mentioning is that very few places in Erode accept credit cards.  There are a few ATM's available.  But I'd recommend bringing enough cash to last you.

Guest House vs. Hotel

Dining area at the guest house
Before I arrived, one of the doctors that had written me suggested that many choose to move into a hotel after a few days in the hospital's guest house (actually guest apartments, owned by the Chairman).  When I looked online at hotels, it looked like they were a bit far from the hospital, so I decided I would start at the guest apartment and get a lay of the land.  My concern was that the guesthouse would be on the hospital premises, which could feel a bit claustrophobic.  The one I stayed in was a 10-15 minute walk from the hospital.  It is a very basic apartment, clean, but a bit sparse.  Two of us were staying here, each with our own room.  The hospital also provided a housekeeper who came by a couple of times a day to cook lunch and dinner for us and to clean our rooms, and do laundry.  She was a lovely woman, even though we didn't speak one another's languages.  The rooms each had a bed and a bathroom and importantly, an air-conditioner and ceiling fan.  The living-room, dining-room, and kitchen did not have air-conditioning.   It would have been nice to have one in the living room area, just to make it nicer to socialize.  Because we're here at the hottest time of year, my colleague and I would eat together, and then go to our rooms where it was cool.  I recommend that you pay it "as you go" in case you decide to move out to a hotel.  There are two guest apartments, one for men and one for women.  I believe we actually stayed in the one designated for the women, and from what I understand, this is the only one that has a cook.  Clarify that with Anitha when you talk about the details.

The wireless internet at the apartment was pretty good, but would tend to drop out at times.  It was fast enough for most everything, but it was a too choppy to do video Skype.

Bedroom at the guesthouse
The other doctor, who was here for a month, stayed at the Radha Prasad Hotel.  It was quite a nice place, with fairly modern rooms, cable TV, a nice restaurant and rooftop swimming pool, and it only cost $20 per day (welcome to India!).  The hotel is too far from the hospital to walk in the heat and the traffic, so he took rickshaw taxis back and forth a total of four times a day, for about 50 rupees (or 75 cents) a ride.  The meals at the hotel are inexpensive, and they have room service, so you don't have to sit and order for every meal.  Because he was staying for so long, they gave him courtesy English speaking channels on the TV and did his laundry for free.  He had internet, but I'm not sure how good it was.  I think with meals and transportation, his costs were $30 per day.  The hotel is quite a bit nicer than the guest apartment.  You can compare that with the costs they give you for a room in the guest apartment.  There are other hotels around, but I'm not familiar with them.

Living room at the guest house
In the end, I decided to remain at the apartment for a few reasons.  First, I liked being within walking distance of the hospital and not having to deal with taking transport back and forth. Second, I really liked our cook.  She made Indian food for every meal, which I love.  (We each paid 1200 rupees for two weeks worth of meals, which is about $20.)  And it was easy to just walk out into the dining room and eat whatever she had made instead of going through a menu for every meal.  I enjoyed having meals with my colleague who was staying in the apartment.  Our schedules did not always match, but we usually ate together once a day.   I am also the kind of guy that likes being in the neighborhood rather than a hotel, and my needs are pretty basic, so the room in the apartment suited me well.

I am glad I brought earplugs.  It is a bit noisy at night, and though I never sleep with earplugs other than on a plane, I'm glad I had them with me.  They helped block out the noise and I slept soundly.  The Radha Prasad Hotel, though also on a busy street, seemed quiet inside.

The Daily Schedule

You're here to learn surgery.  So, your main time is in the operating room.  Every evening, Anitha will send you a message telling you what time your cases start the next morning.  In terms of required time, you just need to be there for your cases.  That's all.  But there are some other learning opportunities available.

With some of the OR staff
The morning OR time is for residents and people receiving training.  There are two operating rooms, each with up to three surgeries going simultaneously.  Morning surgery starts around 7 AM, and can go until 2 PM.  The hospital closes from 2-4 PM for lunch.  At 4 PM, the attending physicians (or "consultants" as they are called here), do their surgery until 6 PM or later.  If you are here to learn phaco, it's good to attend the afternoon surgery and watch.  There are monitors connected to most of the microscopes.  For SICS, I did not find it very useful, because most of the attendings are doing phaco.  I did attend a few sessions of surgery in the afternoon, but for me, who already is well-versed in phaco, it was more social than surgical.  I did enjoy watching a combined phaco-trab.  I also discovered that the residents do surgery on Saturday mornings.  This isn't time that we had surgery scheduled, and I realized that for those of us learning SICS, sitting in and watching the resident's surgery would be very useful.  Unfortunately, this opportunity wasn't communicated.

In the evening, if you wish, you can also go to the post-op ward.  The "sisters," as the nurses are called, will ask you for your initials and how many cases you did that morning.  They will then round up your patients and bring them for you to examine.  Post ops are not typically seen by the operating surgeon, but rather examined two days post op by the residents in the post op clinic.  I went every day.  It's good feedback to see how your patients look after your surgery, and I would highly recommend doing this.  You don't see the patients pre-op.  You just do the surgery.

There is also the opportunity to attend the outpatient clinics.  I never did.  If you are early in your career, or have a particular interest, I suppose it could be enjoyable.

Apparently, there are also lectures at 4 PM on most days.  I probably would have attended some if I had known about it earlier in my stay.  This is the sort of thing I think could be improved -- being handed a written schedule of the hospital happenings upon arrival, so you can know what opportunities are available.

Outpatient clinic area
So, at the fullest, you could arrive for your surgical cases in the morning at 7 AM, stay on for morning clinics, have a lunch break from 2-4 PM, be back in surgery to observe at 4 PM, see your post ops at 6 PM, and then go home for the evening.

Of the three of us who were here this month, none of us did all of that.  I went for my surgical cases, finishing up by 9-10:30 AM or so on the days when I had 3-5 cases, and finishing at 1-2 PM on the days I had 8-9 cases.  And then I came briefly back to the hospital at 6 PM to see my post ops.  The first two or three days I went to watch surgery at 4 PM.  So, basically, I was in surgery for a part of the morning, and the rest of the entire day was free, except for 15 minutes seeing the post-op patients in the evening.

The doctor that was learning PPV only went to the operating room for his cases, which were for a few hours in the mornings.

And the third doctor that was here to learn SICS and phaco did what I did, although he usually attending the 4 PM OR time to watch phaco, and also attended some clinics.

The OR is open for surgery in the mornings on Monday, Tuesday, Thursday, and Friday.  Nothing on Wednesday or Saturday (except resident cases Saturday mornings).  So, putting this all together, what it means is that you have a lot of free time.  A lot.  If you have an average of 4 cases a day, you'll be done before noon every day, and you may choose to come for 15 minutes in the evening to see post ops.  So, bring something to keep yourself busy.  I was a bit puzzled by this, wishing the surgical schedule was more full, but on the days I did do 8 or 9 cases, I was totally exhausted, and it really was too much.  You do need to start off slowly.  So just have some things to occupy yourself.  It's unusual to have as many as 8 cases a day.  Because my stay was unexpected cut short by the election, they wanted to make sure I got my allotted 30 cases while I was here, so they loaded the cases heavy at the beginning of that week.


The walk to the hospital.  The road doubles as the sidewalk.
The town is a bustling mid-size Indian city.  If you are from the West, you'll be shocked by the seeming random pattern of the traffic, the absence of sidewalks, the noise.  I loved it all.  But I'm sure some could find it overwhelming.  And the town does not really have much in it, in terms of tourist sites.  Take a look at Trip Advisor to get a sense of things you might want to do.  North of the guesthouse, there is a park, and on the weekend I took a walk through it, and paid 10 rupees to enter some kind of a sanctuary, which was a nice walk.  And I did some shopping for my family.  But other than that, there was not much else to see or do.  So again, bring something to keep yourself occupied.

Extra Touches

The hospital has a few SIMS cards available which you can use while you are here and insert in your phone.  This gives you a local number while you are here, and makes it easier to communicate with the hospital and gives you internet data access at local rates.

The hospital also has a driver, and on a couple of occasions, Anitha arranged for him to take me to some shops to buy souvenirs for my family.  That was nice, and I enjoyed getting to know the driver.

Trip to the Eye Factory

One of the things that Anitha does is to arrange a weekend trip for you to a company that produces IOL's and other surgical equipment and ophthalmic products.  I remember visiting the Alcon headquarters in Fort Worth, Texas many years ago, and I imagined it would be a similar experience.  I didn't go, because I didn't want to spend 5 hours driving there and 5 hours driving back.  But the week before my arrival, one of the other doctors went, and he said that other than the drive, which was painful, it was an enjoyable excursion.  The company puts you up in a nice resort hotel, pays all the expenses for the weekend, and has some executives dine with you.  It's in Pondicherry, which is on the ocean, and supposed to be a nice resort town.

The Training

The training itself was quite good, and I would recommend it.  After all, there are few places you can go, and get hands-on experience, with good instructors, for 2-4 weeks.  The primary instructor for me was Dr. Vinit, who had completed his residency at Arasan just 6 months ago.  The residents get tremendous surgical experience here.  Dr. Vinit was great surgeon, and a helpful teacher.  He did the first case, explaining each step, then let me loose to do the rest.  During the first week, he was always gloved and gowned, and I had him step in quite a few times when I was uncertain, mostly because it is a human being that you're operating on, and I didn't want to risk complications.  So, if a capsulorhexis was going astray and I was having difficulty getting it to recover, or if I noticed a zonular dialysis, or was having difficulty prolapsing the nucleus, I'd have him step in and show me how to do it.  After all, I'm not here to prove anything.  I'm here to learn.

By the end of the first week I felt fairly comfortable with all the steps of the surgery, and had quite a few cases that went comfortably from start to finish.  But I did find that it was a difficult transition to make from phaco, mostly because once you have gotten the hang of it, phaco is so nice.  Easy incision, nice getting the lens out, a tiny incision with a foldable lens, and you're done!  Dr. Vinit told me, as I was sharing my frustration, that SICS is much harder to master than phaco, and takes much longer to learn.  The incision has blood, the tunnel takes time, the incision is large, prolapsing the nucleus can be challenging, it can be awkward getting the lens in, so generally, it can feel frustrating.  It's all part of the process.  He also told me that if it were easy, I wouldn't have to come here to get training.  Good point.  By the end of the second week, I was comfortable and confident, which I did not expect to happen in just two weeks, but it did.  My cases were going smoothly, and I realized, "wow, I've learned how to do this!"

Extra Steps to Improve Your Learning

Besides the instruction, there are a few things you can do yourself to improve your learning experience.

1.  Record and watch your cases.  One thing that one of the doctors I had contacted before I arrived told me was to bring a USB stick (thumb drive, pen drive, flash drive) and ask them to record your cases.  Give them the "pen drive" (which is what they call them here -- if you use one of the other terms, no one will know what your'e talking about), and ask them to put your cases on it.  They will have the pen drive ready for you around 4 PM, and that evening, it can be useful (but painful) to review your cases to look for areas of improvement.

2.  Get recordings of your instructor's cases.  One of the things that I found even more useful was to ask them to put a few cases from your instructor on the pen drive.  Most of them have a case file on the computer, and it can be a great help to study these.  Even though there are lots of videos on YouTube, there is nothing like watching the specific technique of your instructor.  I wish I had been able to do this in advance, and it's one area where Arasan needs to raise its presence -- more online videos.

3.  Use the wet-lab.  I incidentally found out that there is a wet lab available.  I spoke to the Chairman about getting in there, and so he arranged for one of the senior residents to accompany me one evening.  They gave me three cadaver eyes, and I spent 45 minutes or so practicing tunnel incisions.  It was very worthwhile, and I went into surgery the next day, much more confident about that step of the procedure.  The senior resident guided me and made recommendations and answered questions I had very ably.

4.  Ask for fresh blades when you need them.  Blades are reused.  If you are used to using a fresh blade with each case, you'll find this a struggle.  I had a lot of trouble with my scleral tunnels, but when I realized that a big part of it was because of the dullness of the blade, and I asked for a new blade, everything went so much better.  You're paying for the training, so don't worry about the cost of the blades.

Things Arasan Could Do Better

Based upon some of the things mentioned above, there are some things that Arasan could do better.  They are not major, and could probably be fully implemented within 2 weeks.  I think they would significantly improve the experience of those being trained, and also just give a sense that things are well-organized.

1.  Add some formal elements to the training.
  • Recommend texts or videos for candidates to study before arrival.
  • Make recordings of cases available online for candidates to study before arrival.
2.  Improve organizational elements
  • Prepare a printed weekly hospital schedule for candidates so that they know what is going on throughout the hospital each day and what learning opportunities are available to them.
  • Have a formalized system where their cases are automatically recorded and the nurses automatically ask them for a pen-drive and put the cases on it for them.  Right now, if this happens, it is completely at the initiative of the doctor being trained, and the nurses seem a bit unsure about recording, transferring files to the USB, etc.  It's an important teaching tool. Make it a part of the program.
  • Make a folder of video recording, by instructor and case type, available to all candidates upon their arrival.  The nurses should ask each doctor for their USB drive, and transfer the folder onto it for them.
  • Make candidates aware of the free time before they arrive for their training and encourage them to come prepared with something to keep them occupied.
3.  Generally, I think if Arasan thought of it as a "course" instead of simply "surgical training", it would help them develop the program.  A "course" implies formal organizational elements, which currently are a bit lacking.  It is currently mentorship in the operating room.  Having the organizational elements above, and perhaps adding time where the instructor would review your surgical recordings with you, or go over the instructor's surgical recordings would add a didactic element that could greatly improve the teaching.

A Great Experience, and Solid Training

In my two weeks at Arasan, I completed 40 cases.  After the last day of surgery (today), I felt like I had mastered the surgery.  I'm sure there will still be a lot to learn in the next 100 cases.  I would definitely recommend the training at Arasan.  Both my colleagues felt the same.  The one who got phaco training hopes to come back in a few months, after having done some cases in his home country.  He felt the same as I did -- the instructors were exceptional, and the volume was great.  My colleague who received PPV training spoke very highly of it.  He now feels comfortable doing basic PPVs -- enough to clear out a vitreous hemorrhage, or to removed a dropped nucleus/IOL, and to fix retinal detachments without PVR.  He felt it was very worthwhile, and relatively inexpensive.

It was a great experience.  There are a few things Arasan could to do make the experience better and smoother, but the key elements are here:  the quality of the instruction and the volume of the cases.

Info about Arasan can be found on their website, and on their Facebook page.

Our trainer, Dr. Vinit, in the center.

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