this retrospective study included 112 eyes of 83 consecutive patients with mature cataracts who all had extracapsular cataract extraction with scoli between may and december 2008 .
all surgeries were performed using topical anesthesia ( proparacaine hydrochloride , 4 times in 15 min before surgery ) by a single experienced surgeon ( jun yang ) .
a 1.0-mm paracentesis is made at 2 oclock in the limbus with a 15 blade while the eye is stabilized and pushed downward by grasping in the limbus with a 0.12 toothed forceps .
the eye is stabilized by grasping in the paracentesis . a composite photograph of making a subconjunctival limbus oblique incision , ( a ) a paracentesis is made with a 15 blade , ( b ) the 3.0 mm keratome is placed parallel to the posterior sclera , 0.5 mm behind the conjunctival - limbal insertion , 90 to the right side of the paracentesis , ( c ) a 3.0 mm transconjunctival sclerocorneal tunnel is fashioned with a keratome , ( d ) the dissected pocket is extended temporally , ( e ) the pocket is extended nasally up to the limbus , ( f ) an inverted 
is created a uniplanar transconjunctival tunnel ( oblique plane incision ) is fashioned with a 3.0 mm keratome ( sharpoint , usa ) , 90 to the right side of the side port ( oblique location ) .
the knife is placed parallel to the posterior sclera , 0.5 mm behind the limbal vascular arcades , and pressure is slightly applied to indent the limbus with the knife , pushing forward to begin the transconjunctival tunnel incision [ fig .
1b ] . when the knife tip approach 1 mm into clear cornea , the eyeball is rotated slightly backward to enable the knife tip penetrate the descemet 's membrane .
the knife is then inserted until the  shoulders  are at the internal corneal incision [ fig .
a subconjunctival limbal tunnel is subsequently created with an angled bevel - up crescent blade ( sharpoint , usa ) beneath the conjunctival / tenon 's tissue .
the dissected pocket should extend temporally and nasally up to , but should not cut the limbal vascular arcades on either side .
its transverse extent is greater in the cornea ( 9.0 mm ) than in the limbal opening ( 7.0 mm ) [ fig .
the crescent blade is then used to cut remaining adherent tenon 's tissue in a way perpendicular to corneal limbus to create an inverted 
l  conjunctival pocket . with two straight edges being 3 mm and 4 mm in length
thus , a limbal tunnel covered partially by conjunctiva - limbal attachment is created . as only little
bleeding occurs , cautery is typically not necessary . a 7.0 mm capsulorhexis is performed using a pair of capsulorhexis forceps [ fig .
a sinskey hook is used to extract one pole of the nucleus and rotate in a clockwise direction , until a half of the nucleus is in the anterior chamber [ fig .
2b ] . using toothed forceps to grasp the side incision and rotate the eye downward a little
, a vectis may be passed into the anterior chamber and under the half - dislocated nucleus [ fig .
the external foramen of the tunnel can be opened a little using downward pressure of the  heel of the vectis [ fig .
2d ] . the bulk of the nucleus can then be lifted and drawn into the tunnel [ fig .
when the nucleus is passing through the incision , epinucleus may strip off , or the nucleus may fragment . however , in most cases , the nucleus should be delivered in whole [ fig
. 2f ] . a composite photograph of extracting the nucleus outside the capsular bag and subconjunctival limbus incision , ( a ) 6.0 mm capsulorhexis is performed using a pair of capsulorhexis forceps , ( b ) a sinskey hook is used to extract one pole of the nucleus outside the capsular bag , ( c ) a vectis is passed into the anterior chamber and under the half - dislocated nucleus , ( d )
the external foramen of the tunnel is opened a little using downward pressure of the  heel of the vectis , ( e ) the bulk of the nucleus is passing through the conjunctival pocket , ( f ) the whole nucleus is delivered from the eye , ( g ) a 5.5 mm 3-piece pmma lens is implanted into the bag , ( h ) final redeepening of the anterior chamber is done , ( i ) a limbal incision partly covered by conjunctiva - limbal attachment is created
. 1 = corneal lip ; 2 = limbal cut ; 3 = inverted  l  conjunctival opening after cortex is removed , a 5.5 mm 3-piece pmma lens is implanted in the bag [ fig .
final deepening of the anterior chamber ( with 500 mg/100 ml vancomycin in ringer lactate solution ) ( about 1.0 mg ) is done to reach an intraocular pressure slightly higher than normal ( t + 1 ) [ fig .
the uncorrected and best - corrected visual acuity ( bcva ) was measured 3 months after surgery .
the central corneal endothelium was examined with a specular microscope ( sp 8000 konan medical inc ) .
surgically induced astigmatism was calculated using the vector analysis method based on the keratometry results of corneal topography examinations ( orbscan iii , bausch and lomb inc ) .
postoperative topographic changes were determined by subtracting the preoperative readings from the postoperative numerical map readings .
a 1.0-mm paracentesis is made at 2 oclock in the limbus with a 15 blade while the eye is stabilized and pushed downward by grasping in the limbus with a 0.12 toothed forceps .
the eye is stabilized by grasping in the paracentesis . a composite photograph of making a subconjunctival limbus oblique incision , ( a ) a paracentesis is made with a 15 blade , ( b ) the 3.0 mm keratome is placed parallel to the posterior sclera , 0.5 mm behind the conjunctival - limbal insertion , 90 to the right side of the paracentesis , ( c ) a 3.0 mm transconjunctival sclerocorneal tunnel is fashioned with a keratome , ( d ) the dissected pocket is extended temporally , ( e ) the pocket is extended nasally up to the limbus , ( f ) an inverted 
conjunctival pocket with an opening of 5 mm is created a uniplanar transconjunctival tunnel ( oblique plane incision ) is fashioned with a 3.0 mm keratome ( sharpoint , usa ) , 90 to the right side of the side port ( oblique location ) .
the knife is placed parallel to the posterior sclera , 0.5 mm behind the limbal vascular arcades , and pressure is slightly applied to indent the limbus with the knife , pushing forward to begin the transconjunctival tunnel incision [ fig .
1b ] . when the knife tip approach 1 mm into clear cornea , the eyeball is rotated slightly backward to enable the knife tip penetrate the descemet 's membrane .
the knife is then inserted until the  shoulders  are at the internal corneal incision [ fig .
a subconjunctival limbal tunnel is subsequently created with an angled bevel - up crescent blade ( sharpoint , usa ) beneath the conjunctival / tenon 's tissue .
the dissected pocket should extend temporally and nasally up to , but should not cut the limbal vascular arcades on either side .
its transverse extent is greater in the cornea ( 9.0 mm ) than in the limbal opening ( 7.0 mm ) [ fig .
the crescent blade is then used to cut remaining adherent tenon 's tissue in a way perpendicular to corneal limbus to create an inverted  l  conjunctival pocket . with two straight edges being 3 mm and 4 mm in length
thus , a limbal tunnel covered partially by conjunctiva - limbal attachment is created . as only little
bleeding occurs , cautery is typically not necessary . a 7.0 mm capsulorhexis is performed using a pair of capsulorhexis forceps [ fig .
a sinskey hook is used to extract one pole of the nucleus and rotate in a clockwise direction , until a half of the nucleus is in the anterior chamber [ fig .
2b ] . using toothed forceps to grasp the side incision and rotate the eye downward a little
, a vectis may be passed into the anterior chamber and under the half - dislocated nucleus [ fig .
the external foramen of the tunnel can be opened a little using downward pressure of the  heel of the vectis [ fig .
2d ] . the bulk of the nucleus can then be lifted and drawn into the tunnel [ fig .
when the nucleus is passing through the incision , epinucleus may strip off , or the nucleus may fragment . however , in most cases
2f ] . a composite photograph of extracting the nucleus outside the capsular bag and subconjunctival limbus incision , ( a ) 6.0 mm capsulorhexis is performed using a pair of capsulorhexis forceps , ( b ) a sinskey hook is used to extract one pole of the nucleus outside the capsular bag , ( c ) a vectis is passed into the anterior chamber and under the half - dislocated nucleus , ( d )
the external foramen of the tunnel is opened a little using downward pressure of the  heel of the vectis , ( e ) the bulk of the nucleus is passing through the conjunctival pocket , ( f ) the whole nucleus is delivered from the eye , ( g ) a 5.5 mm 3-piece pmma lens is implanted into the bag , ( h ) final redeepening of the anterior chamber is done , ( i ) a limbal incision partly covered by conjunctiva - limbal attachment is created
. 1 = corneal lip ; 2 = limbal cut ; 3 = inverted  l  conjunctival opening after cortex is removed , a 5.5 mm 3-piece pmma lens is implanted in the bag [ fig .
final deepening of the anterior chamber ( with 500 mg/100 ml vancomycin in ringer lactate solution ) ( about 1.0 mg ) is done to reach an intraocular pressure slightly higher than normal ( t + 1 ) [ fig .
patients were examined preoperatively and on 1-day , and after 3 months postoperatively . the uncorrected and best - corrected visual acuity ( bcva ) was measured 3 months after surgery .
the central corneal endothelium was examined with a specular microscope ( sp 8000 konan medical inc ) .
surgically induced astigmatism was calculated using the vector analysis method based on the keratometry results of corneal topography examinations ( orbscan iii , bausch and lomb inc ) .
postoperative topographic changes were determined by subtracting the preoperative readings from the postoperative numerical map readings .
the mean age of the 83 patients was 67.2 years  9.3 ( sd ) ( range 68 to 86 years ) .
there were 41 male patients ( 40.2% ) and 42 female patients ( 59.8% ) .
preoperative uncorrected visual acuity in all 112 eyes ranged from light perception to 20/200 . in 73 eyes ( 65.2% ) ,
the mean surgical time was 3.75  1.1 min ( range 1.5 to 4.5 min ) .
sutureless wounds were achieved in all but 2 patients , who required 2 sutures to close the main wound .
the intraoperative complications included hyphema in 3 eyes ( 2.7% ) , irregular conjunctiva tear in 10 eyes ( 8.9% ) , iridodialysis in 2 eyes ( 1.8% ) , descemet 's membrane detachment in 5 eyes ( 4.5% ) , posterior capsular rupture and zonular dialysis in 2 eyes ( 1.8% ) .
on the 1 day postoperatively , folds in descemet 's membrane were observed in 13 eyes ( 11.6% ) ; 9 were moderate corneal edema limited to the incision area ( 8.0% ) .
a transient increase in intraocular pressure ( > 25 mm hg ) was observed in 11 eyes ( 9.8% ) .
fifteen patients ( 13.4% ) reported a minor superior foreign - body sensation , which resolved within the first 48 h of surgery .
no other significant intraocular complications such as endophthalmitis , retinal detachment or epithelial ingrowth occurred in the study .
there are 67% patients at 1-day and 81% at the 3 months post - operative visit achieved a ucva of 20/40 or better , 91% patients at the 3 months post - operative visit achieved a bcva of 20/20 or better [ figs . 3 and 4 ] .
two eyes with a post - operative corrected visual acuity of 20/200 or worse had chorioretinal atrophic changes in the macula [ figs . 3 and 4 ] .
frequency histogram of ucva 1-day and 3-mon postoperatively frequency histogram of bcva 3-mon postoperatively the mean preoperative and postoperative 3 months astigmatism was 0.71 d  0.55 d , 1.5 d  0.73 d , respectively .
the mean ( sd ) sia in 25 patients preoperative astigmatism within  0.5d was -0.62d  0.41d at a mean axis of 135.0  15 calculated using the vector analysis method [ fig . 5 ] .
the frequency distribution of sia by vector analysis at three months postoperatively the mean preoperative endothelial cell density per millimeter squared were 2300  313 , 3 months after surgery were 2200  475 ( p < 0.05 ) .
the average number of cells lost per patient was 114  21 per millimeter squared .
the present study reports a novel incision technique ( scoli ) and its outcomes in manual cataract extraction for mature cataracts . in this study ,
98% eyes ( 110/112 ) of the wounds were self - sealing , 81% eyes ( 68/84 ) achieved ucva of 20/40 or better at the 3-month follow - up . there was a low rate ( 4.2% ) of endothelial cell loss , which was compared favorably with endothelial cell loss reported for manual sics , especially for large and dense cataracts . despite an average surgical time of 3.75 min per case ,
the surgical complication rate was low , with less than a 2% rate of vitreous loss .
clinical outcomes of this study demonstrated that the scoli technique is a safe and effective alternative to msics for mature cataracts .
for standard extracapsular cataract extraction ( ecce ) , the surgical limbus is the primary choice for incision site .
however , this entrance approach ca nt yield a long enough tunnel for a self - closed wound . in msics ,
the external incision is moved to a more posterior location to promote better self - sealing of the wound .
while this incision may be sufficient for cataracts of mild to moderate density , it is sometimes difficult to deliver a large , hard nucleus without fragmentation . in scoli
, the location of the external entry has been shifted back toward the limbus approach .
the shorter tunnel length ( 1.5 mm ) permits easy delivery of a large nucleus . in this series ,
the nucleus was delivered in whole in 108 eyes ( 96.4% ) . in 3 eyes ,
if it is a small fragment , it can be removed by hydroexpression ; if it is large , it should be pushed back into the anterior chamber with viscoelastic before reattempting .
only 1 eye may need nucleus fragmentation with the second instrument through the side - port incision .
it has been found that the shorter tunnel in scoli allows easy delivery of large nucleus safely and effectively using a vectis . this subconjunctival limbal incision is essentially composed of 3 staggered incisions in alignment as follows : the innermost corneal lip being 9 mm in width ; the intermediate scleral - corneal cut being 7 mm in width and the outermost inverted 
2i ] . with a smaller conjunctival pocket ( 5 mm in width ) , the limbus - corneal tunnel is covered by conjunctive / tenon 's tissue [ fig .
, the natural elasticity of conjunctival - limbal attachments enhances the wound stability by decreasing sliding between the two lamina of the tunnel . besides , conjunctival tissue heals quickly , is usually subject to fibrosis / coagulation , and forms rather strong adhesive bonds making the incisions more secure .
thanks to the elasticity of the conjunctival tissue , the smaller size conjunctival opening ( 5.0 mm in width ) does not constitute a barrier to nucleus expression and lens implantation [ fig . 2e and g ] .
the key step in this technique involves making a tunnel length proportional to the nuclear sclerosis and widening of the limbus tunnel beneath the conjunctival pocket . in msics ,
here we created the scoli from inside to out and this needed a great deal of surgical expertise . though difficult , it gives increased wound integrity and is quick in the hands of experienced surgeon . in a high volume setting ,
the scoli , because of its location and its architecture , induces less iatrogenic astigmatism .
the super - oblique incision contributes to less surgically induced astigmatism ( sia ) than with a superior incision .
the scoli technique is free of cautery , minimizing the damage to sclera and its associated astigmatism . importantly , as mentioned above , the scoli gives increased wound integrity .
where we keep the integrity of tunnel intact , without stretching or tearing of the internal incision , we can minimize sia .
in our series , vector analysis demonstrated a mean sia of -0.62d  0 . 41d post - operative 3 months , which is similar to others reports .
local anesthesia is routinely used in msics , primarily because of intraoperative pain resulting from trauma / cautery as well as placing a bridle suture for akinesia . in scoli , less surgical trauma to conjunctive / sclera decrease the peroperative requirements for analgesia .
meanwhile , the side paracentesis enables the surgeon to control the movement of the eyeball using a forceps , decreasing the necessity for a rectus bridle suture .
these merits contribute to the less - invasive characteristics and bring the trend toward topical anesthesia .
in fact , this limbal incision can be easily extended if conversion to conventional ecce is necessary .
conversely , by enlarging the incision , we can easily convert phacoemulsification into sclol with this technique , especially in eyes with large and hard nuclei . in conclusion , we present here a novel cataract incision technique that allows removal of a large , hard nucleus via a shorter sutureless incision .
this scoli is free of performing a peritomy and can be performed under topical anesthesia , decreasing operative time and minimizing the damage to limbal architecture .
therefore , this technique has the potential to serve as safe and effective technique for mature cataracts .
 aims : to report the technique and outcomes of sutureless manual cataract extraction via a subconjunctival limbus oblique incision for mature cataracts.materials and methods : this retrospective study comprised of 112 eyes of 83 patients with mature cataract who all had manual cataract extraction via a subconjunctival limbus oblique incision . 
 a transconjunctival tunnel is fashioned with a 3.0 mm keratome , 0.5 mm behind the limbal vascular arcades . 
 a limbal tunnel , with a transverse extent of 9 mm in the cornea and 7.0 mm in the limbus , is created beneath the conjunctival / tenon 's tissue using an angled bevel - up crescent blade . 
 outcome measures included visual acuity , intraoperative complications , surgically induced astigmatism , endothelial cell loss rate and surgery time.results:self-sealing wound was achieved in 112 eyes ( 98.2% ) . 
 the nucleus was delivered in whole in 108 eyes ( 96.4% ) . 
 intraoperative complications included hyphema in 3 eyes ( 2.7% ) , iridodialysis in 2 eyes 1.8% ) , posterior capsular rupture and zonular dialysis in 2 eyes ( 1.8% ) . 
 at the 3-month follow - up , 91% patients achieved a best - corrected visual acuity of 20/20 or better , the mean of surgically induced astigmatism was -0.62  0.41 diopters and endothelial cell loss was 4.2% . 
 average surgical time was 3.75 min per case.conclusion:this subconjunctival limbus oblique incision has the potential to serve as safe and effective technique for mature cataracts . 
Materials and Methods
Surgical technique
Examinations
Result
Discussion