dr.sandhya. b
TRANSCRIPT
“A COMPARATIVE STUDY OF VISUAL OUTCOME AND
COMPLICATIONS IN PHACOEMULSIFICATION AND MANUAL
SMALL INCISION CATARACT SURGERY AT RAJARAJESWARI
MEDICAL COLLEGE AND HOSPITAL BENGALURU”
By
Dr.SANDHYA. B
DISSERTATION SUBMITTED TO
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,
BENGALURU
In partial fulfillment of the requirements for the degree of
MASTER OF SURGERY (MS)
IN
OPHTHALMOLOGY
Under the Guidance of
Dr.NITHISHA.T.M, MS
PROFESSOR
DEPARTMENT OF OPHTHALMOLOGY,
RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL,
BENGALURU, KARNATAKA.
2017 - 2020
I
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled "A COMPARATIVE
STUDY OF VISUAL OUTCOME AND COMPLICATIONS IN
PHACOEMULSIFICATION AND MANUAL SMALL INCISION
CATARACT SURGERTY AT RAJARAJESWARI MEDICALCOLLEGE
AND HOSPITAL, BENGALURU "is a bonafide and genuine research work carried
out by me under the guidance of Dr. NITHISHA.T.M MS, Professor, Department Of
Ophthalmology, Rajarajeswari Medical College and hospital, Bengaluru, for the award of
M.S. Degree (Ophthalmology), examination to be conducted by the Rajiv Gandhi
University of Health Sciences, Bengaluru. This is an original work and has not been
submitted by me for any other Degree or Diploma in any other University.
Date: // / J I / J o / 1
Place: BENGALURU
lJ
f3 -CJ~o{ ~ SIGNATURE OF TH1 ·cANDIDATE
Dr.SAND HY A .B
Post Graduate Student,
Department of OphthaJmology,
Rajarajeswari MedicaJ College
& HospitaJ, Bengaluru
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled "A COMPARATIVE STUDY OF
VISUAL OUTCOME AND COMPLICATIONS IN PHACOEMULSIFICATION AND
MANUAL SMALL INCISION CATARACT SURGERY AT RAJARAJESWARI
MEDICAL COLLEGE AND HOSPITAL, BENGALURU"is a bonafide research work
done by Dr.SANDRY A. B under my supervision and guidance, in partial fulfillment of the
requirement for the degree of MASTER OF SURGERY in OPHTHALMOLOGY.
Date 11 / 1 I I J o I t:j
Place: BENGALURU
NJ~l-t rT-M SIGNATURE OF THE GUIDE
Dr. NITHISHA. T.M MS
Professor,
Department of Ophthalmology,
Rajarajeswari Medical College and
Hospital, Bengaluru
Ill
Or. Nithi~ha T.itt P:of;::;.;_,:~r
f'cpt. ot Opl.thalr•.r; 'ogy KMC No. 557v8
RRMC&H , Bangalore
ENDORSEMENT BY THE HOD/ DEAN OF THE INSTITUTION
This is to certify that the dissertation entitled "A COMPARATIVE
STUDY OF VISUAL OUTCOME AND COMPLICATIONS IN
PHACOEMULSIFICATION AND MANUAL SMALL INCISION CATARACT
SURGERY AT RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL,
BENGALURU" is a bonafide research work done by Dr.SAND HY A.B under the
guidance of Dr.NITHISHA.T.M MS, Professor, Department of Ophthalmology,
Rajarajeswari Medical College And Hospital,in partial fulfillment of the requirement
for the degree of M.S. (OPHTHALMOLOGY)
~ Signature and Seal of the HOD
Dr. KAUSHAL KUMAR, M.S.
Professor and Head
Rajarajeswari Medical College and
H~~·k:r~~~,,~L }( -~. ::_: "., 1
;:, JC 1 .:::G f\ :J <'-~ S4L OEPARTME1\fr OF Oi ;rl"I ; IALMOLOGY
Date: 11/ 11 l W1NyH Place: BENGALURU
rv
~~~ . Signature and Seal of the DEAN
Dr. SATHYAMURTHY. B.,M.S
Professor and Dean
Rajarajeswari Medical College and and Hospital, Bengaluru
DEAN . Rajarajeswari Medical College & Hospital
•<arnbipura, Mysore Road
Date I lo/3/'fJ'f!J.'Hf f fGO 074.
Place: BENGALURU
COPYRIGHT
DECLARATION BY THE CANDIDATE
I, Dr.SAND HY A.B of Rajarajeswari medical college and hospital hereby
declare that the Rajiv Gandhi University of Health Sciences, Kamataka, shall
have the perpetual rights to preserve, use and disseminate this dissertation I thesis
in print or electronic format for academic/research purpose.
Date: l! j J I /J_ o ) ?
Place: BENGALURU
A-f~ ¾>. SIGNATURE OF THE CANDIDATE
Dr.SANDHYA.B
Post Graduate Student,
Department of Ophthalmology,
Rajarajeswari Medical College
& Hospital, Bengaluru
© Rajiv Gandhi University of Health Sciences, Karnataka
V
I
A CKNQWLEDGEMENT
At this outset, I thank Almighty for showering his blessings on me and giving me
the strength to perform all my duties. As I complete this humble contribution to
scientific pursuit, it gives me immense pleasure to acknowledge all those who helped
me in this endeavor.
It is my proud privilege and deep sense of respect I would like to express my
gratitude and indebtedness esteemed regards and sincere thanks to my Guide
Dr.NITHISHA. T.M, MS Professor, Department of Ophthalmology, for the guidance,
constant encouragement, and enthusiasm, which he rendered during the pursuit of
my post-graduate studies and in the preparation of this dissertation.
I especially want to thank Prof & Head of department Dr.KAUSHAL KUMAR
for his guidance during my research and study.
I express my sincere gratitude to all the Professors, Associate Professors,
Assistant Professor, and Senior Residents of Rajarajeswari medical college and
hospital for valuable suggestions & support during my study.
I am grateful to Sri A.C. Shanmugam, B.A.L.L.B, the chairman, Dr Satyamurthy B.
, M.S., Dean, Dr. Naveen S., M.S., die Principal and Dr. MK. Govindaraj, MS., Medical
VI
superintendent Rajarajeswari Medical Collage and hospital for permitting me to utilize
the resources in completion of my work
I am thankful to my colleagues, Dr. Remya Joseph parappalli/, Dr. Neethu and
Dr. Mathuri for their support and help throughout the completion of this dissertation
and for excellent co- operation at all times.
I thank the 0. T Staff, Records Section Staff, Library Staff and all Hospital Staff
for their support and co-operation in my study.
I express my most sincere regards and heartiest gratitude to my parents, my
sister and my brother in law who have always supported and nurtured me to become
the doctor and the person I am today.
Last but not the least I would be failing in my duty if I did not express my gratitude
to all my patients and their families who formed the backbone of this dissertation.
Date: I/ / II f J o I 1 Place: BENGALURU
VII
/~ SIGNAT.Ja: dr;~E CANDIDATE
Dr.SANDHYA .B
IX
LIST OF ABBREVIATIONS
AC
ACIOL
Anterior chamber
Anterior chamber intraocular lens
A SCAN Amplitude scan
ATR Against the rule astigmatism
BCVA
B SCAN
Best corrected visual acuity
Brightness scan
CSJ Corneo scleral junction
CCC Continuous curvilinear capsulorhexis
EC Endothelial cell
ECCE Extra capsular cataract surgery
Er:YAG Erbium-doped yttrium aluminium garnet
FLACS Femto second laser assisted cataract surgery
FEF Focused electromagnetic field
ICCE
IOL
Intracapsular cataract surgery
Intraocular lens
IOP Intraocular pressure
MSICS Manual small incision cataract surgery
Nd YAG
OPD
RBS
RRMCH
SIA
Neodymium yittrium aluminium garnet
Outpatient department
Random blood sugar
Raja Rajeswari Medical College and Hospital
Surgically induced astigmatism
UCVA Uncorrected visual acuity
WTR With the rule
XII
LIST OF TABLES
SL.
No.
TABLES Page
No.
1 TYPES OF SURGERY
63
2
AGE DISTRIBUTION
64
3
GENDER DISTRIBUTION
65
4
LATERALITY
66
5
PRE-OPERATIVE VISUAL ACUITY
67
6
POST-OPERATIVE UNCORRECTED VISUAL ACUITY
AT 1ST WEEK
68
7
POST-OPERATIVE UNCORRECTED VISUAL ACUITY
AT 2ND WEEK
69
8
POST-OPERATIVE UNCORRECTED VISUAL ACUITY
AT 6TH WEEK
70
9
POSTOPERATIVE BEST CORRECTED VISUAL ACUITY
AT 6TH WEEK
71
10
TYPES OF SURGERY vs SURGICALLY INDUCED
ASTIGMATISM
72
11
TYPES OF SURGERY vs POST-OPERATIVE
REFRACTION AT THE END OF 6TH WEEK
74
12
TYPES OF SURGERY vs INTRA-OPERATIVE
COMPLICATIONS
75
13
TYPES OF SURGERY vs POST-OPERATIVE
COMPLICATIONS
76
XIII
LIST OF FIGURES
SL.
No.
FIGURES
Page
No.
1
SURGICAL ANATOMY OF LIMBUS 10
2
INCISIONAL FUNNEL 18
3
CLEAR CORNEAL INCISION AND SCLERAL TUNNEL
INCISION
24
4
INCISION ANATOMY 42
5 TYPES OF SURGERY 63
6
AGE DISTRIBUTION 64
7
GENDER DISTRIBUTION 65
8
LATERALITY 66
9
PRE-OPERATIVE VISUAL ACUITY 67
10
POST-OPERATIVE UNCORRECTED VISUAL ACUITY
AT 1ST WEEK
68
11
POST-OPERATIVE UNCORRECTED VISUAL ACUITY
AT 2ND WEEK
69
12
POST-OPERATIVEUNCORRECTED VISUAL ACUITY
AT 6TH WEEK
70
13
POSTOPERATIVE BEST CORRECTED VISUAL
ACUITY AT 6TH WEEK
71
14
MSICS vs SURGICALLY INDUCED ASTIGMATISM
73
XIV
15
PHACO EMULSIFICATION vs SURGICALLY
INDUCED ASTIGMATISM
73
16
TYPES OF SURGERY vs POST-OPERATIVE
REFRACTION AT THE END OF 6TH WEEK
74
17
TYPES OF SURGERY vs INTRA-OPERATIVE
COMPLICATIONS
75
18
POST –OPERATIVE COMPLICATIONS -MSICS
76
19
POST –OPERATIVE COMPLICATIONS
– PHACOEMULSIFICATION
77
20
SURGICAL STEPS –MSICS
CONJUCTIVAL PERITOMY
103
21 SCLERO CORNEAL TUNNEL
103
22 SIDE PORT ENTRY 103
23 TRYPHAN BLUE STAINING OF AC 103
24 CAPSULORHEXIS 104
25 KERATOME ENTRY 104
26 NUCLEUS REMOVAL 104
27 RIGID IOL IMPLANTATION 104
28 SURGICAL STEPS –PHACOEMULSIFICATION
SIDE PORY ENTRY
105
XV
29
TRILAMINAR INCISION 105
30
STAINING OF AC WITH TRYPHAN BLUE 105
31
CAPSULORHEXIS 105
32
MAKING OF TRENCH 106
33`
DIVIDE AND CONQUER 106
34
IRRIGATION AND ASPIRATION 106
35
FOLDABLE IOL INJECTION 106
STRUCTURED ABSTRACT
TITLE: A Comparative study of visual outcome and complications in phacoemulsification and
manual small incision cataract surgery.
BACKGROUND AND OBJECTIVES: Objective of the study was to compare the visual outcome and complications following manual small incision cataract surgery and phacoemulsification and to suggest on the most suitable treatment option in developing countries. .
METHODS: The sample comprised of 200 eyes from 200 patients were studied for a period of 1
year.100 patients were enrolled into MSICS and 100 into phacoemulsification. They were asked
to follow up on 1st week, 2nd week and 6th week. During their follow up visual acuity,
slit lamp examination and fundoscopy was done.
RESULTS: In our study, the most common age group was 51-60. Females being more
than males. The most common pre-operative visual acuity range was 6/60-6/24. At 1st week,
46%of patients had uncorrected visual acuity of >6/18 in the MSICS group and 73% in the
phaco group. At 2nd week, the UCVA improved in the MSICS group to a greater extent. At the
end of 6 week,74% patients achieved >6/18 uncorrected vision in the MSICS group and
93% of patientsachieved the same vision in the phaco group. The best corrected visual acuity
achieved was 98% in both the groups with low complication rates. Most of the patients in the
MSICS group had ATR astigmatism whereas in phaco group majority of the patients had no
astigmatism.
INTERPRETATION AND CONCLUSION
Though phaco group had better visual outcome in the follow up weeks, the visual outcome in
the MSICS drastically improved over the weeks. Equal number of patients achieved BCVA in
both the groups at the 6th week with low complication rates. Thus MSICS being cost effective,
less technology dependent and less learning curve needed can be accepted as an alternative to
phacoemulsification.
KEYWORDS: cataract; MSICS; phacoemulsification; complications; astigmatism
X
1
INTRODUCTION
TITLE: Comparision of visual outcome and complications following phacoemulsification
and manual small incision cataract surgery
Cataract is the most common cause of curable bilateral blindness due to
increasing age.1It is irreversible opacification of lens or capsule due to denaturation of lens
proteins. It causes gradual, painless progressive diminision of vision and is potentially a
blinding condition.2If left untreated cataract can lead to various complications like lens
induced glaucoma and uveitis.3Cataract is treatable4 through cataract surgeries. Manual
small incision cataract surgery (MSICS) involves instruments to remove cataractous lens
from the eye through a small incision. Phacoemulsification involves using a high
frequency ultrasound probe to fragment the nucleus.1To overcome the burden of cataract
blindness there must be sufficient surgical coverage and good surgical outcomes4 viz
safety, early rehabilitation and post operative emmetropia.5
The risk factors for cataract are multifactorial. Apart from age, etiological
epidemiological studies have identified a number of risk factors for cataract 6, 7 gender,
diabetes mellitus, sunlight, steroids, nutrition and socio-economic status, life style-
smoking and alcohol dehydration/diarrheal crises. More recently data emerging from
genetic studies estimate that the heritability of age related cataract could be between 48% -
59%.8, 9 Phacoemulsification has emerged in the recent years as the most popular
procedure to treat patients with cataract in the industrialized world.10, 11 The reason for this
popularity are that phacoemulsification is safe5 and gives better visual outcomes4 such as
early rehabilitation and emmetropia. However several studies have shown that despite
phacoemulsification surgery being popular in developed countries it is not suitable for
developing countries10,11 that has a significant backlog of patients requiring surgery, as the
technique is associated with high costs including the cost of phaco machine, maintenance
and staff wages and the cost of consumables.
2
Driven by the need for more cost effective options, an increasing trend in
developing countries is the use of manual suture less small incision cataract surgery
(MSICS),which some have claimed is comparable to phacoemulsification in terms of
obtaining excellent visual outcome being faster, less costly, less technology dependent and
less learning curve. MSICS also have similar intraoperative and postoperative
complications. The considerable handling inside the anterior chamber during nucleus
delivery increase the chance of iris injury, striate keratitis and posterior capsular rupture.
The expected post operative complications are corneal edema, uveitis and sometimes
descemets membrane detachment in MSICS. They are rare if the surgeon have the
expertise and patience. In MSICS the location, size, shape of the incision used greatly
influence the surgically induced astigmatism which in turn influence the visual outcome
.so it is crucial for the surgeon to determine all three factors pre operatively to reduce the
surgically induced astigmatism. Major complications in phacoemulsification are posterior
capsular tears with vitreous loss, isolated posterior capsular tears, phaco burns and
sometimes corneal edema that depend on the phaco time. There is however a concern of
posterior capsular opacification in the long term that needs to be addressed.12, 13 It is
therefore critical that MSICS to be evaluated as a cost effective alternative to
phacoemulsification for the developing countries.
3
OBJECTIVES
To compare the visual outcome following cataract surgery.
To compare the complications following cataract surgery.
To make recommendations on the most suitable surgical options for
cataract in developing countries such as INDIA.
4
REVIEW OF LITERTATURE
EPIDEMIOLOGY
According to a recent survey globally 285 million people are visually impaired, 246
million have low vision and 39 million people are blind.65% of visually impaired people
and 82% of all the blind are elderly. In India 62.619 million people are visually
impaired.54.544 million has low vision and 8.075 million people are blind accounting for
20.5% of the global blindness burden. India is second only to china in the high prevalence
of visual impairment and blindness.14
The principal cause for visual impairment worldwide include uncorrected refractive
errors ( 43%) and cataract (33%).14 Globally senile cataract is also the leading cause of
blindness except in the most developed countries.14,2\ It accounts for 48% of
global blindness which represents 18 million people currently. It is also estimated that the
current estimate of 20 million cataract blind will double by the year 2025.2 The burden of
cataract blindness is highest in developing countries. In India alone an estimated 9 million
people are cataract blind and additional 1.8-3.8 million go blind from cataract every
year.15,16 90% of patients had IOL implantation .16 Thus we see that India still needs to
increase the cataract surgical rate to combat cataract blindness.
HISTORICAL ASPECTS
The surgical treatment of cataract is an ancient art that goes to the Stone Age.
Sushruta practiced couching as early as 800 B.C. With the help of Larg’s twin knives, one
of which has a sharp tip the other was blunt. The first is introduced into the AC and then
rapidly withdrawn without the loss of aqueous; the second is inserted through the corneal
puncture and used to force the lens backwards and downwards until it lies on retina
5
anterior to the equation. Thereafter, the patient is nursed sitting up in bed or in an easy
chair 17.
Jacques Daviel (1745), a French man published the first account of extracapsular
cataract extraction through an inferior limbal incision. But for a considerable period
couching remained the standard method of treatment With regards to astigmatism it was
Donder in 1864, who first showed that an unwelcome consequence of cataract surgery is
an alteration in corneal curvature.
A German ophthalmologist, Albrecht Von Graefe (1860), improved upon
extracapsular technique with development of a knife that created a better apposed wound.
In 1903, Colonel Henry Smith developed the technique of intracapsular cataract
extraction (ICCE)
Barraquer (1917) devised a suction apparatus and cup to extract lens by pneumatic
suction.
Harold Ridley 1949, an English ophthalmologist developed modern intraocular
lens implantation.18 (1951) developed ECCE - ACIOL.
Tadeusz Krwawicz in Poland (1961) developed cryoprobe. This instrument would
form an ice ball, fusing the lens capsule, cortex and nucleus lessening the risk of capsular
rupture as the cataract was removed from the eye.
Charles Kelman of New York developed phacoemulsification in 1967. The
sophisticated instrument used in this surgery allows the cataractous lens to be removed
through a very small (3.2mm), beveled incision.18
Mazzocco introduced foldable IOLs in 1984.
6
Richard Kratz developed scleral tunnel incision 1980. In early 1982 Kraff and
Sanders proved that smaller incisions were better than larger, producing less early induced
astigmatism and less late healing astigmatic shift.
Peter Kansas described manual phacosection technique (1986). Shepard
contributed a large break through with astimgatically neutral horizontal suture 1989.
In 1984, Howard Gimbel and Thomas Neuhany simultaneously and
independently developed capsulorhesis and published joint article in 1990 .19
Richard Kratz has originally described the scleral pocket incision surgery.
Koch P. (1991) has described a structural analysis of cataract incision
construction.
Mike Mc Farland MD., from Pine Bluffs Arkansas has described the
concept of corneal valve incisions self sealing wound.
Howard Fine (1992) Welsh Cataract Conference in Houston had
described the clear corneal incisions. Langerhan's (1995) has described the corneal hinge
incision.
Gerald T. Keener described the nucleus division technique for small
incision cataract surgery, which in time has come to be referred to as the phacofracture
technique.
The next technique to be reported was the phacosandwitch technique in
1985, by Luther Fry.
Albrecht Hennig 1997 introduced Fish hook technique for nucleus
extraction.20
7
Singer advocated frown incision, Pallin introduced chevron incision in 1991
to reduce the surgery induced astigmatism.
Blumenthal described hydro expression of the nucleus (1992) and
popularized the small incision technique. 21 Fine in 1992 described a new concept of a
planar temporal clear corneal suture less incision.
Kratz was credited as the first surgeon to move from the limbus posterior
to sclera, increasing the appositional surfaces to enhance wound healing and attempt to
exert less traction on the cornea, thereby controlling surgically induced astigmatism.
Phakonit is the latest technique of phacoemulsification first devised by Dr.
Amar Agarwal (India). The advantage of Phakonit over conventional phacoemulsification
is that here the size of incision is below 1mm .22
Laser cataract surgery is a technique similar as phacoemulsification
procedure; in this cataract surgery instead of ultrasound power laser energy is used. The
rhexis can be done with laser also. Two types of laser systems are being used for laser
cataract surgery Nd: YAG and Er: YAG15.22
Phacotmesis technology started by Dr. Aziz Anis for cataract removal that
combines high speed (4000-5000 rpm) rotation and ultrasonic linear oscillation at the
probe tip.22
Focused electromagnetic field (FEF) technology is plasma blade of complex
system that vaporizes the surface molecules of a hair tine plasma probe, thereby forming a
microscopic cloud of cutting plasma particles around the probe. Dr. Richard Fugo who
devised this technology.22
8
Femtosecond laser assisted cataract surgery (FLACS) is a recent
development in the history of cataract surgery. Femtosecond laser uses short pulse
duration in the femtosecond range (10-15 seconds).20 The femtosecond laser works on the
principle of photo disruption: converting laser energy into mechanical energy. This is
brought about by a tightly focused beam of ultra short pulses of light energy with enough
peak power to create plasma.21-23 This plasma free of electrons and ionized molecules
rapidly expands, and cavitation bubbles that enlarge and coalesce are then created, being
able to separate tissues.
RELEVANT ANATOMICAL FACTS FOR CATARACT SURGERY
Before actually embarking on cataract surgery, it is essential to know the
relevant structural details of the tissues to be manipulated for the cataract surgeon.
The structures include
1. Bulbar conjunctiva and Tenon's capsule.
2. Limbus
3. Sclera
4. Cornea
5. Anterior chamber (AC)
6. Lens and zonnules
1. BULBAR CONJUCTIVA AND TENON’S CAPSULE
This portion of conjunctiva is loosely attached to underlying Tenon's capsule and
sclera by connective tissue strands.
About 3mm from corneoscleral junction (CSJ), it becomes more closely attached to
Tenon's which in turn fuses with sclera 1.5mm posterior to CSJ. Thus it is important to lift
tissue within 3mm of CSJ.
9
The conjunctiva possesses a fair measure of elastic tissue. This entails that a
mobilized fornix based flap can sufficiently cover the corneoscleral wound with minimal
undermining.
2. LIMBUS
Accurate knowledge of the surgical anatomy of the limbus is important with
respect to the placement and direction of incision into the chamber angle. The limbus is
the entire translucent zone between sclera and cornea where the opaque sclera and the
conjunctival tissue overlap the transparent cornea.
Anatomically the limbus may be described as being bounded anteriorly by a line
drawn between the ends of Bowman's and Descemet's membranes, peripherally by the
opaque sclera, internally by the trabecular meshwork and schlemm's canal, and externally
by the conjunctiva and that portion of the fascia bulbi known as Tenon’s capsule. Kasner
is the one, who popularized the correlation between external landmarks at the limbus and
the internal structures of the angle.
The external landmarks of the surgical limbus are the :
Anterior limbal border (Corneo limbal junction) is identified by the insertion of the
conjunctiva and Tenon capsule into the cornea, which creates a prominent ridge.
This ridge overlies the termination of Bowman's membrane. If the limbus is dissected free
of conjunctiva a bluish transparent zone of 1 to 1.2mm wide at the superior limbus is seen
just posterior to the anterior limbal border. Adjacent to this bluish zone posteriorly is the
white sclera. The line formed where the white and blue tissues intersect marks the middle
of the superior surgical limbus and is called the mid limbal line. It overlies Schwalbe's
10
line, which marks the termination of Descemet's membrane. Posterior limbal border
(sclero limbal junction) lies 1mm posterior to mid limbal line .24 It lies approximately over
the scleral spur.
The width of the blue limbal zone depends upon the insertion of the
conjunctiva and Tenon's capsule into the cornea, which varies in different quadrants. Their
most anterior insertion is in the superior quadrant, where the blue limbal zone is
approximately 1mm wide. The insertion is more posterior nasally and temporally, where
the blue limbal zone decreased to a width of only 0.4mm. Inferiorly the width of the blue
limbus zone is 0.8mm. The width of the surgical limbus is greatest in the superior
quadrant, which is to the surgeon’s advantage.
FIGURE 1: SURGICAL ANATOMY OF LIMBUS
11
3. SCLERA
Sclera forms the posterior four fifth part of the globe, with an anterior opening
for the cornea and a posterior opening for the optic nerve. Tenon’s capsule invests the
sclera and rectus muscle anteriorly, and both are overlaid by the bulbar conjunctiva. The
capsule and conjuctiva fuse near the limbus. The sclera is thinnest 0.3mm behind the
insertions of the rectus muscles and thickest 1.0mm at the posterior pole around the optic
nerve head. It measures 0.4 to 0.5mm at the equator and about 0.8 adjacent to the limbus
25. Its radius of curvature is 12mm26.
4. CORNEA
Cornea occupies the center of the anterior pole of the globe. In the adult, it
measures about 12mm in horizontal meridian and about 11mm in the vertical from behind,
viewed at its posterior landmark (Schwalbe’s line). The cornea and aqueous humor
together form +43D in air and constitute the main refractive element of the eye. Because
the posterior surface of the cornea is more curved than the anterior surface, the central
cornea is thinner (0.5mm) than peripheral cornea (0.7mm). The cornea becomes flatter in
the periphery. Flattening is more extensive nasally and superiorly than temporally and
inferiorly. The anterior and posterior radii of curvature of the central part of the cornea are
7.8mm and 6.5mm, respectively25.
Corneal endothelial cell (EC) morphology and density has an important bearing
on the visual prognosis in cataract surgery. This innermost layer of cornea is essential for
relative dehydration and hence transparency of cornea by its active pumping out of excess
fluid back into AC. The normal thickness of cornea is 0.02mm in the centre and 0.65 in
periphery.
12
Endothelial cell density tends to decrease with age, from 3000/cu. mm in young
children to about 2000/cu.mm in patients in cataract age group. If we take this as an
average preoperative endothelial count and consider 500cell/cu.mm as the minimal
number required to maintain corneal dehydration, then a 20% cell loss during surgery still
appears justifiable.
.
5. ANTERIOR CHAMBER (AC)
AC is the space where most of the steps of MSICS are effected. Normal
central depth of AC is 3.5mm and normal diameter is 12.5mm. Though the most common
diameter of an AC IOL is 12.5 mm; white-to-white measurement of the individual cornea
is indispensible.
The zonules are directed slightly posteriorly from the anterior capsule due to
posterior location of ciliary ring compared to the lens plane. This tends to keep anterior
capsule stretched. When the AC is opened during cataract surgery, the shallowing of AC
and subsequent anterior lens movement increases the zonular pull on the capsule. Thus it
is essential to keep AC deep during capsulotomy as even momentary shallowing may
cause an uncontrolled tear to extend to the periphery. Also, a collapsed cornea at any stage
of operation might touch the lens, the IOL or any instrument resulting in irreversible
damage to the delicate endothelium.
6. LENS
The crystalline lens is covered by its capsule. It is thicker anteriorly than
posteriorly, especially between anterior pole and equator. This anatomical fact limits the
size of anterior capsulotomy, which must not be more than 7mm to avoid uncontrolled
tears. At the same time, a capsulotomy smaller than 5mm makes nucleus expression
13
difficult and risky. Thus the optimum size of a capsulotomy is 6mm, the range being 5-
7mm.
In most children and some adults, the posterior lens capsule is adherent to the
vitreous face where it forms the anterior surface of patellar fossa. The high mitotic activity
of epithelium in equatorial bow in these age groups necessitates a primary/secondary post
capsulotomy with anterior vitrectomy, or lensectomy to clear the visual axis.
The transition from peripheral cortex to central nucleus is gradual with an
intermediate zone called `epinucleus' that exhibits transitional characteristics and behaves
as a coat to the central nucleus. These intermediate properties are used to advantage in
making a smaller limbal section or scleral tunnel where in by hydrodissection and
hydrodelineation the size of nucleus is reduced to a point where it can be extracted
piecemeal or emulsified without enlarging the section beyond IOL optic diameter.
The size of nucleus and its hardness determine the section size and in
phacoemulsification, the mode of cleavage. According to a grading by `Jaffe' et al based
On its colour, it can be graded from –
1+ to 5+:
1+ Transparent and clear
2+ White
3+ Yellow
4+ Amber, and
5+ Brown or black.
14
ASTIGMATISM BASIC CONCEPT
The change in astigmatism following any ocular surgery is known as surgically
induced astigmatism (SIA). Cataract surgery by nature is refractive surgery, as surgically
induced refractive changes are a result of cataract extraction, intraocular lens implantation,
and incisional corneal astigmatic changes.
Change in corneal curvature is a well documented finding after cataract surgery
and this induces a change in astigmatism which reflects the SIA. SIA is one of the major
obstacles in achieving good visual rehabilitation because it necessitates spectacle wear for
clear vision which is not desirable by most of the patients in view of the cost as well as the
inconvenience.
In order to control the post-operative astigmatism and to keep it at minimum
one needs to know about the source of the astigmatism. It can be either preexisting or
induced astigmatism. Total pre-existing astigmatism of the eye has a corneal and a
lenticular component 27. But after cataract surgery, in pseudophakic eyes, the lenticular
component is not significant and corneal component is responsible for most of the residual
astigmatism. It can be measured by standard keratometry or corneal topography. The
surgically induced astigmatism can be easily calculated based on the change 28 in
keratometry reading after surgery.
15
–
-
CALCULATION OF SURGICALLY INDUCED ASTIGMATISM
The amount of SIA, can be calculated by comparing pre- and
postoperative keratometry values with vector or polar analysis. 28, 29 Using standard
keratometry as a sole guide to astigmatism planning can be at times misleading because it
fails to identify any irregular astigmatism which can limit optimum surgical results. In
such cases corneal topography would be the preferable 30.
The spherical component can be analysed without difficulty but the problem
resides with the cylindrical component. The cylinder is denoted by a magnitude expressed
in diopters and a direction reported in degrees. For statistical analysis of such directional
data these values must be converted to vectors or as polar values 28, 31.
In this method the cylinder is considered as a vector (magnitude and
direction). The refractive error, which is expressed as sphere, cylinder, and axis, is
converted to a vector and then the vectors can be compared 29.
This technique was specifically developed for analysis of the astigmatic
component of refractive surgery. The refractive data is converted to polar values which
characterizes regular astigmatism completely.31, 29
16
FACTORS AFFECTING SURGICALLY INDUCED ASTIGMATISM
SIA depends upon various factors like type of incision, size and location of
the incision, placement of any suture, suture material used and technique of suturing ,
amount of scleral cauterization, use of steroids post operatively and also on the pre-
existing astigmatism.32,33,34,35,36,37,38,39,40 Each of these factors play an important role in
determining the final post operative residual astigmatism.
Incision characteristics are “the” most important factor in determining the
amount of surgically induced astigmatism. In a cataract surgery an incision has to be
described in terms of its position, location, distance from the limbus, size and distance
from the limbus.
Any cataract incision ultimately tends to flatten the cornea in the meridian
of the incision. The amount and stability of corneal flattening is dependent on the
incisional design and location, the use of cautery, sutures and the length of time since the
surgery. Wound compression by sutures and cautery initially tends to steepen the cornea in
the meridian of the incision, with a gradual relaxation over time. A predictable change in
magnitude and minimal change in direction of incision increases the refractive value of a
specific incision
The development of scleral pocket incision by Richard Kratz (1980) came
about as a way of reduction the level of astigmatism caused by the wound. Thrasher and
Boerner showed that 9 mm posterior incision induces less astigmatism than 6 mm limbal
incision. Use of scleral pocket incision brought another development in suturing
technique.
17
Michael S.MacFarland (1990) eliminated sutures completely by
construction self sealing sclero-corneal pocket tunnel incision.24 Long term evaluation of
the results and stability seems to indicate that scleral tunnel without suture closure are
relatively stable and induced minimal astigmatisms.
.
Studies showed that 3.2mm clear corneal incision results in 0.5D of SIA.41
On further decreasing the length of incision to <2.5mm does not give any advantage in
terms of astigmatic change because of the stretching of the wound during IOL
placement.41,42 SIA is highest with corneal incisions, intermediate with limbal and
minimum with scleral incisions.
Temporal scleral wounds are purported to cause less astigmatism than
superior wounds as they are farthest away from centre of the cornea and therefore least
likely to affect the corneal curvature in the visual axis 43. However most surgeons prefer
doing superior incision because of wide dissection field.
An important concept in understanding incision design in SICS is that of
the incisional funnel, postulated by Paul Koch. This is an area bounded by a pair of
curvilinear lines whose shape is based upon the relationship between astigmatism and two
characteristics of the incision – length and distance from limbus. Incisions made within
this funnel are astigmatically stable.
18
FIGURE 2: INCISIONAL FUNNEL
Short linear incisions made close to the limbus and longer incisions
farther away are equally stable. The frown incision or the Chevrolet ‘v’ incision
incorporate a larger incision into this funnel and hence are more desirable. Clear corneal
tunnels have significant demerits – difficulty in obtaining square geometry due to limited
length of tunnel, difficulty in anterior chamber manipulation .44
It has been suggested that a 3mm clear corneal incision has least
surgically induced astigmatism compared to 2.5mm or 3.5mm incisions .33
Presence of a large preoperative astigmatism, a low postoperative IOP results
in more against-the-rule surgically induced astigmatism 37. It has also been shown that the
postoperative astigmatic shift is same with mersilene and nylon suture.38, 39 Use of
excessive scleral cautery induces significant astigmatic change during cataract surgery. 40
INCISIONAL
FUNNEL
LIMBUS
19
Several studies have found a strong correlation between corneal astigmatism
and refractive astigmatism after PCIOL implantation, suggesting that the IOL itself was
astigmatically neutral. Lens tilt has been suggested as a possible cause of post surgical
astigmatism. Significant tilting is required to induce clinically significant cylinder. A 20D
IOL must be inclined 10° from vertical plane to cause 1 D of cylinder.45, 46
PRE OPERATIVE WORK UP
All surgeon desire to have emmetropia (‐0.50 to 0.00 D) in both eyes for their
patients post-operatively. Other options include maintaining myopia in patients with
pre‐existing myopia or monovision, where emmetropia in one eye is combined with a
degree of myopia in the fellow eye to decrease spectacle dependence at distance and near.
Biometry is most commonly performed by applanation A‐scan, immersion
A‐scan or by optical coherence using the IOL Master.The IOL Master is generally
considered to be the most accurate and the gold standard but it cannot be used with very
dense or mature cataracts or in patients with poor fixation. In contact lens wearers, soft
lenses should be discontinued for 24 to 48 hours and rigid lenses discontinued up to two to
three weeks prior to performing biometry to stabilise the keratometric readings.47 Once the
corneal curvature and axial length measurements are determined, several IOL formulae are
available and each has its indications and some are better at predicting IOL power in
excessively short or long eyes. The A‐constants of lenses could also be modified from the
manufacturer's values based on each surgeon's outcomes.
With current IOL formulae and the use of the IOL master, the target refraction is achieved
within one dioptre in 96 per cent cases.48 Axial lengths outside of the range of 21.3 to
26.6mm and asymmetry of mean keratometric findings of greater than 0.90 dioptres and
20
keratometric values outside 41.0 to 47 D, astigmatism greater than 2.5 dioptres, axial
length asymmetry of more than 0.7 have also been suggested as parameters to alert the
surgeon to recheck values.One of the most common causes are an inaccurate axial length
in cases where an ultrasonic applanation is used instead of optical coherence because
excess contact causes compression of the eye and thus a shorter axial length. Inaccurate
axial lengths can also occur in high myopes in the presence of a staphyloma. Another
increasingly common cause of inaccurate refractive outcomes is prior laser refractive
surgery. Due to changes in the corneal curvature as the result of laser surgery, the
keratometric findings obtained by the IOL master or manual keratometry are inaccurate as
the current IOL formulae assume a relationship between the anterior and posterior
curvatures of the cornea that no longer apply. Improved results can be obtained if the
refraction and K values pre‐ and post‐LASIK are available or with new technology such as
the Pentacam (Oculus) to measure corneal power and using specially developed formulae
such as the BESSt formula.49
CATARACT SURGICAL TECHNIQUES
Cataract is treatable through cataract surgery. Surgery is indicated once
the patient vision drops to a level wherein it interferes with the patients quality of life.2The
technique of cataract extraction has witnessed major advancements in the recent years.
A wide variety of surgical techniques are available for cataract
extraction and IOL implantation which include extracapsular cataract extraction and
intracapsular cataract extraction .The extracapsular cataract extraction technique include
conventional technique, small incision cataract surgery and phacoemulsification.
In the intracapsular cataract surgery technique the whole lens along with
the capsule was removed through a large 12mm corneal incision that required suturing.
21
This resulted in large surgically induced astigmatism and thus delayed visual
rehabilitation. It was also associated with high rates of posterior segment complications
like retinal detachment because of the pressure on the vitreous body during the procedure.
The patients were left aphakic and were corrected with thick aphakic glasses which caused
poor image quality due to image distortion and magnification. But this procedure was very
popular in the developing countries in the past because it was quick and cost-effective
with very short learning curve.
In 1960s, the technique of cataract surgery was modified and Extracapsular
cataract extraction (ECCE) was introduced. Here the cataract was removed from the
capsular bag and the posterior capsule was left behind for placement of posterior chamber
intraocular lens in the capsular bag. The presence of an intact membrane between the
aqueous and the vitreous reduces the incidence of post operative complications like
cystoids macular edema, retinal detachment and post operative glaucoma..Many
techniques of ECCE has been introduced which includes conventional technique, small
incision cataract surgery and phacoemulsification.
Conventional technique involves 10-12mm corneal incision followed by
manual expression of entire lens and implantation of intraocular lens in the capsular bag.
The large corneal incision requires suturing which results in unwanted astigmatic errors.
But the visual outcome in terms of image qualitywas better in ECCE than ICCE.
In developing countries, a high volume of cataract surgeries have to be
performed to combat the large backlog of cataract patient. So a simple, cost-effective,less
technology dependent and time saving procedure has to be performed to manage this
backlog. One such procedure is Manual Small Incision Cataract surgery .In this procedure
22
,the cataractous lens is removed through a 5-6mm incision.This is followed by placement
of Intraocular lens in the posterior capsular bag .
ANAESTHETIC CONSIDERATIONS
For cataract surgery, several methods of anaesthesia are available and depend on
surgeon preference. Most cases are done under local anaesthesia, with general anaesthesia
reserved for patients intolerant of local anaesthetic for any reason. The preference for local
anaesthesia is not only the faster recovery time for the patient but also the decreased risk
of systemic complications of general anaesthesia and the decreased cost. We preffered
peribulbar anaethesia in this study.Well versed surgeon use topical anaesthesia, using
paracaine eye drops followed by intracameral lignocaine 1% preservative free. The main
advantage of topical anaesthesia is the lack of complications associated with a block and
the immediate improvement in vision, which both enhances all patients' peri‐operative
experience and helps only‐eye patients to see. It can also help the surgeon if the patient
retains ocular motility during surgery. No studies showed increased risk of complications
associated with topical anaesthesia.
23
MANUAL SMALL INCISION CATARACT SURGERY
INSTRUMENTS
- Lid speculum
- Forceps
- Muscle hook
- Superior rectus holding forceps
- Conjuctival scissors
- Blade 15 number and scalpel
- Cresent knife
- Side port
- Keratome 5.2mm
- Cystitome (bevelled up)
- Iris dialing hook
- Vectis
- Simcoe cannula
INCISION
A sclera tunnel incision has 3 components.
EXTERNAL SCLERAL INCISION
A half thickness perpendicular external sclera groove is fashioned with
cresent knife or Bard parker knife. The groove is located 2.5 to 3mmfrom surgical limbus
and could be parallel, linear or frown shaped.
If the incision is curvilinear, the potential for wound gape and ATR
astigmatism is more.
If it is linear, the risk of wound gape and ATR astigmatism is reduced.
If frown shaped, there is maximum stability to the wound and ATR is least.
24
FIGURE 3: INCISIONAL ANATOMY
25
SCLEROCORNEAL TUNNEL
The horizontal tunnel is dissected with a bevel up blade parallel to the
sclera, splitting its lamellae. It is extended upto 1 to 1.5mm into the clear cornea.
INTERNAL CORNEAL INCISION
This is created using a sharp 3.2mm angled keratome. The heel of the
keratome is raised till the blade becomes parallel to the iris plane and keratome tip creates
a dimple in the cornea. Next the keratome is advanced in the same plane till the AC is
entered. The incision may be extended according to the optic size of IOL to be inserted.
It is the actual entry into the eye and therefore has greater influence on
astigmatism and wound stability than the external incision. The corneal valve incision
confers the self sealing property to the incision. This technique avoids suture induced
astigmatism.
TEMPORAL INCISION
Temporal incision has immense number of advantages.
There is no need to turn the eyedown, as when working over the brow, and
therefore the bridle sutures, are not necessary.
� With the iris plane parallel to the light of the microscope, the red reflex is enhanced, and
there is marked improvement in visualization of intraocular structures allowing greater
access to the incision, than when working over the brow.
� At this location, the lateral canthal angle is directly beneath the incision, the irrigation
fluid drains naturally.
26
� The temporal location is farthest from the visual axis, and thus the endothelial damage,
post operatively, is much less than superiorly placed incisions
� Any flattening around the wound is less likely
to affect the corneal curvature at the visual axis in temporal incision.
� Incisions at this location, are more stable with respect to ATR drift.
� It is very convenient to handle the instruments.
� Superior quadrant is available for a future trabeculectomy
� when the incision is located superiorly, both gravity and eyelid blink tend to create drag
on the incision. With temporally placed incision, these forces are better neutralized
because the incision parallel to the vector of the forces.
� At this location, the astigmatism induced, is ‘WTR’. This is advantageous for the large
majority of cataract age patient, whose preoperative astigmatism was ‘ATR’.
OPERATIVE STEPS
STEP 1- PREPARATION
A lid speculum is placed in the operative eye after the eye has been draped and
anaesthetized with peribulbar block.
STEP 2- SUPERIOR RECTUS BRIDLE SUTURE
Superior rectus bridle suture is put with the help of muscle hook depressing the
globe downwards and superior rectus holding forceps.
27
STEP 3- CONJUCTIVAL PERITOMY
The conjunctiva and tenon’s capsule is dissected from the superior limbus for
approximately 3 clock hours and reflected to expose bare sclera.
STEP 4- WET FIELD CAUTRIZATION
Any bleeding vessels on the sclera are cauterized with wet field cautry to
achieve haemostasis.
STEP 5- WOUND CONSTRUCTION
The 5.5mm track for the sclera wound is measured 1mm behind the limus and
the end points of the wound are marked by indenting the sclera using surgical calipers.
Using 15 no blade or crescent blade,approximately ½ thickness sclera groove is
made with 2 backward extensions at each edge.
The two backward cuts of 1-1.5mm are made from each end of the wound.
The sclera tunel is then constructed using an angled crescent blade. The incision
extends approximately2-2.5mm into the cornea. The dissection is carried out to the limbus
on both sides to create a funnel shaped “pocket”.
The crescent blade is then angled to cut backwards to incorporate the backward
cuts into the pocket.
STEP 6- PARACENTESIS
The paracentesis or a sideport is made with a side port blade at 9’o clock in the
peripheral cornea.
28
STEP 7- STAINING WITH TRYPHAN BLUE
After paracentesis, the anterior capsule is stained with tryphan blue especially in
mature cataract injecting via the side port and washed with normal saline.
Before staining the capsule,it is better to inject air bubble into the anterior chamber
to prevent staining of the cornea.
STEP 8- FORMING THE AC WITH VISCOELASTIC
Viscoelastic material (for example methyl cellulose) is injected through the side port to
form anterior chamber and to protect the corneal endothelium.
STEP 9- CONTINUOUS CURVILINEAR CAPSULORRHEXIS
The continuous curvilinear capsulorrhexis is then performed through the
paracentesis using capsulotomy needle.
Once the initial flap has been started this is continued until the entire
capsulorrhexis is completed. Ideally a larger 6-6.5mm ccc done.
STEP 10 – KERATOME ENTRY
The AC is entered using the appropriate size keratome. The keratome is directed
to include the dissected area that has been pre formed with the crescent blade.
This means the internal opening of the funnel is larger than the external opening (this
configuration makes its much easier to deliver the nucleus and retain a watertight wound
without sutures. All cuts are made on the down stroke i.e in to the AC.
29
STEP 11- HYDRODISSECTION
Any irrigating cannula is introduced through the paracentesis. The tip is placed just
under the capsule at 6.30 position,t he fluid will be be seen perfusing under the capsule.
STEP 12- FREEING THE NUCLEUS
The dialer enters the AC and it engages the equator of the prolapsed nucleus.It is now
rotated to the right side and the nucleus in the bag frees up for delivery.
STEP 13- NUCLEUS DELIVERY
Nucleus is delivered by
Bluementhal technique
sandwhich technique
Visco expression
Irrigating wire vectis
Fish hook tchnique
THE BLUEMENTHAL TECHNIQUE 50
Nucleus delivery by this technique is hydrodissection of the nucleus followed by
its hydrodynamic expression. The next step is to engage the nucleus into the wound. The
delivery of nucleus occurs by hydro pressure generated by AC Maintainer.
IRRIGATING WIRE VECTIS
Irrigating wire vectis is use to deliver the nucleus either by hydroexpression or by
visco-expression. It has anterior concave surface and posterior surface. The anterior end
had three 0.3mm openings. The posterior end is attached to syringe or infusion set.
30
Technique is push the viscoelastic and insinuate the irrigating vectis below the nucleus.
Apply counter pressure by holding superior rectus forceps. Now start the irrigation and
pull the vectis out of the wound. Give pressure over the scleral lip posteriorly. Pressure
must be built up in the anterior chamber before pulling the nucleus out. Posterior lip
depression is important part of nucleus delivery.
VISCO EXPRESSION51 :
This is another technique of removal of nucleus out of the wound. Push
viscoelastic into the anterior chamber. While pushing the viscoelastic engage the nucleus
into scleral lip and then apply pressure over the posterior sclera lip and deliver the nucleus
out. Viscoelastic is continuously pushed while removing the nucleus.
PHACOFRACTURE52 :
Described by Peter Kansas. Viscoelastic is pushed both above and below the
nucleus in the anterior chamber. The solid curved vectis is insinuated under the nucleus
and the nucleotome is positioned on the anterior surface of nucleus. Both instruments are
brought close to each other. This will lead to splitting of the nucleus in to two halves. Both
the halves are separated and each half is removed with nuclear forceps or by pushing
viscoelastic inside the AC.Complications are damage to iris tissue, capsular disruption can
occur, corneal damage.
a) Bisector technique - This requires the use of bisector in place of nucleotome.
b) Using trisector51-The trisector consists of 2 longitudinal limits which are sharp in
the posterior end.
31
c) Phacosalute and fracture - The superior portion of the nucleus is then amputated or
pinched off using a capsular forceps and expressed using a irrigating vectis. Disadvantage
is Corneal endothelial damage.
d) Use of snare (wire loop) - This technique was introduced by Gerard Keener in 1983.
He made a snare using 18-19G blunt tipped needle and 32 G steel wire. The lens loop /
snare is passed below the nucleus. The lens is shifted into vertical position and brought
across the nucleus. The loop is constructed by pulling posteriorly on the coil. This leads in
the division of nucleus into the halves. Each halve is the removed with fine toothed
forceps.
Advantages are safe and non-expensive technique, used for hard cataract, can also be used
in cases of zonular dehisences. Disadvantages are difficult in small pupils, soft nuclei and
subluxated lens, some damage to the corneal endothelium.
PHACO SANDWHICH TECHNIQUE 53, 54:
This technique was introduced by Luther L Fry. The lens loop is placed beneath
the nucleus and spatula is placed on top of nucleus. Both instruments are approximated
leading to sandwiching of the nucleus. Advantages are can be used for all pupil sizes and
almost all types of nucleus. Disadvantages are not suitable for very soft cataract, increase
chance of damage to the posterior capsule and iridodialysis.
Modifications : The instruments used are plain wire vectis and viscocannula. The plain
wire vectis is insinuated below the nucleus and viscoselastic is pushed above and below
the nucleus. The viscocannula is placed in front of the nucleus. Sinskey Hook can also be
used instead of cannula.
32
STEP 14- CORTEX REMOVAL
An another side port is made at 3’o clock position for Irrigation and aspiration.
Cortex extraction is performed with double port irrigation and aspiration.
STEP 15- IOL INSERTION AND IMPLANTATION
A 6-6.5mm rigid lens is inserted into AC through the wound and is placed in the
posterior capsular bag. viscoelactics should be used before IOL insertion to maintain AC
and to prevent endothelial injury.
The optics of IOL is dialed with dialer into the capsular bag in a clockwise direction.
STEP 16- WOUND HYDRATION
The side ports are hydrated by intrastromal injection of irrigating fluid to prevent any
leakage from paracentesis.
STEP 17- SUBCONJUCTIVAL INJECTION
The conjunctiva is reapproximated to the limbus and cauterized to cover the wound.
At last subconjuctival injection of 0.25ml of dexamethasone and gentamycin to be given
and eye to be patched.
CLOSURE OF THE INCISION
Most of the sclero-corneal pocket incisions are self sealing. Sutures are
required when wound construction is defective and fluid is leaking from anterior chamber
and Vitrous loss. An adequate air pressure or fluid pressure in anterior chamber will
tightly shut off the valvular opening. Closure depends on reapproximation of anterior and
posterior surfaces of the tunnel, not on radial compression of anterior and posterior lips of
33
the wound. Cataract wound closure technique has thus shifted from radial sutures to
horizontal sutures.
WOUND HEALING
Healing of Self Sealing Sclero-corneal Tunnel
Scleral pocket incision healing is complex because the initial groove and
peripheral portion of the pocket are in the sclera. The pocket then goes through' the limbus
into the peripheral cornea, and the anterior chamber entry is corneal. Healing process is
different in each of these three zones. Immediately after an incision, corneal fibre swells
in, an effort to seal the opening but scleral fibres tend to contract rather than to swell.
About two days after a scleral incision, histocytes and vascular elements from the
episclera and sub conjunctiva move into the incision and proliferating fibrous tissue begins
to form, running at right angles to the clear cut sclera edges. After several weeks, the
fibres begins to align themselves like scleral fibres but the scar is always histologically
distinguishable. The sclera itself remains relatively inert. In the limbal portion of the
incision, which is entirely midstromal stromal fibrocytes are inactive and play little or no
role in wound healing. Healing of the limbal
stroma also apparently depends upon fibrous ingrowth from the episclera. It may take as
long as two years or more for the stroma to become relatively normal. Once the incision
passes into peripheral corneal stroma, the healing process is
different. Initially after the incisional injury, there is a three to five days lag phase during
which the corneal fibrocytes transform into fibroblast which then form new connective
tissue. At least a month is required for consolidation. At anterior chamber entry, the cut
edges of Descemet's membrane do not reunite. 24 to 48 hours after injury, endothelial cells
at the edge of the wound begins to proliferate by dividing and cover the retracted edges of
34
Descement's membrane, continuing to proliferate, they form a scar over the incisional
area. The proliferating endothelial cells produce a new basement membrane which after
two to three years, thickens to form anew Descemet's membrane about one-half original
thickness. Evidence suggests that scleral pocket incisions probably do not heal any faster
than limbal incisions.
PROS
Small incision 5.5mm sutureless.
Implant rigid lens –“low cost”.
Faster – can be done ±6 minutes.
Useful in high volume cataract surgery.
Low cost equipment and disposables needed.
Successful in more than 99% of cases.
CONS
Larger incision than phaco.
Surgically induced astigmatism is more.
PHACOEMULSIFICATION
In 1967,Charles D Kelman, an ophthalmologist pioneer in cataract surgery
introduced phacoemulsification after being inspired by his dentist’s ultrasonic probe.
Richard kratz and James Little employed a second instrument: two handed
phacoemulsification in the plane of the pupil. This approach involved central sculpting of
the nucleus and then prolapsing the superior equator of the lens into the AC.
Robert Sinskey was the first to intiate one handed phacoemulsification in
the PC, a technique that involved sculpting a bowl out of the nucleus aspirating the rim of
the bowl and emulsifying it.
35
The development of healon by Robert stegmann and David Muller in the
mid 1980s boosted phacoemulsification popularity.
The can opener technique developed and popularized by Dr.Little and
Sinskey was the standard technique for a long time, But it led to capsular tears out to the
equator and haptics being prolapsed into the ciliary sulcus. In early 1980s, Calvin Fercho
began using tearing methods to create circular capsulotomy.
In 1973,Dr Kelman demonstrated grooving the nucleus in the meridian of
the incision and then cracking it. He called this technique as divide and conquer.John
Shepherd took this technique a step further with an insitu phacofracture,in which he
grooved the nucleus in perpendicular meridians,cracked it and emulsified the four
resulting quadrants. These techniques later assumed the name divide and conquer.
Phacoemulsification allows cataract surgery through a small incision that is
stable and usually sutureless. The resultant advantage of rapid patient mobilization and
visual rehabilitation has established phacoemulsification’s deserved current popularity in
cataract surgery.
PHACODYNAMICS
Basic Features :
Every Phacomachine has three basic functions. These are
i. irrigation
ii. aspiration and
iii. ultrasonic fragmentation
36
Correspondingly two hand pieces are used in phacoemulsification
i. the irrigation aspiration hand piece and
ii. phaco or ultrasonic handpiece.
� Irrigation- Aspiration Handpiece :
The irrigation-aspiration (I-A) hand piece has a silicone sleeve that fits snugly
around the aspiration tip. Through this sleeve, irrigation is delievered. The I-A tip differs
from the phaco tip in being smooth and rounded with a single aspiration port on the side of
the tip and not at the end. The sleeve may be turned to orient the irrigation port in any
direction. The irrigation ports in the silicone sleeve should be kept perpendicular to the
metallic aspiration port as this helps to direct the infusion fluid along the iris plane. This
reduces iris flutter during the surgery.
A variety of I-A tips are available: Straight, 45o or 90o angulation; 0.2mm,
0.3mm, and 0.7mm lumen diameters. Most frequently used is the 0.3mm tip. During use
for irrigation aspiration, the foot pedal is in the position 2.
Ultrasonic Handpiece
Phacoemulsification surgery is based on ultrasonic power which is the
function of the acoustic vibrator that has been incorporated into the ultrasonic handpiece.
Attached to this vibrator is a hollow titanium needle or the phaco tip. The acoustic vibrator
is either a magnetorestrictive or piezoelectric device that converts electrical energy under
the influence of an electrical signal. The acoustic vibrator oscillates longitudinally at a
frequency between 30,000-60,000 Hz. This imparts a linear motion to the ultrasonic tip.
The stroke amplitude of the linear movement is 3/100 of an inch and the acceleration
80,000-2,40,000G.
37
Phaco Tip
The energy so produced along the ultrasonic handpiece is then transmitted
onto the phaco tip. The phaco tip is made of titanium and is hollow with the distal opening
functioning as the aspiration port. The phaco tip can have various bevel angles ranging
from 0o -60o most commonly used are 30o & 45o phaco tips.
Aspiration Pumps
Depending on the machine, three kinds of pumps are used to control aspiration
and produce the negative suction pressure i.e. Vaccum. They are
� Peristaltic Pump (constant flow)
Peristaltic Pump was popularized by heart lung machine. In these pumps a
pressure differential is created by compression of the aspiration tubing in a rotatory
motion.
When the rotational speed is low, vaccum develops only when the aspiration
port is occluded. On occlusion, vaccum builds up to preset value in a step ladder pattern.
By increasing the rotational speed, as in the newer generation machines, a linear build of
vaccum occurs even without occlusion of the tip. It can thus be made to stimulate a venturi
or a diaphragmatic pump.
� Venturi pump (constant vaccum)
Venturi pump uses compressed gas to create pressure. Vaccum generated is
related to gas flow which in turn is regulated by a value. Vaccum build up occurs linearly
in a consistent manner from zero to preset value. The buildup is almost instantaneous on
38
pressing the foot pedal. Due to this there is an increased risk of iris trauma and posterior
capsular rents which makes these pumps unsafe, particularly for beginners.
� Diaphragmatic pump (Constant vaccum)
Diaphragmatic pump uses a flexible membrane within a cassette to generate
vaccum. Build up of vaccum is more linear and reaches the preset level even without
occlusion. This makes it unsafe; lens material can be aspirated without having to
mechanically approach it.
� Foot pedal
The model of operation in which the instrument is
functioning on depressing the foot pedal in a linear manner is shown by the position
indicator.
Position 1: Only irrigation solution is flowing.
Position 2: Irrigation and aspiration occur simultaneously.
Position 3: Irrigation and aspiration and fragmentation take place simultaneously.
MECHANISM OF ACTION OF PHACOEMULSIFICATION
Factors involved include:
a. A mechanical impact of the tip against the lens.
b. An acoustical wave transmitted through fluid in front of the tip.
c. Cavitation: At the cessation of the forward stroke, the tip has imparted forward
momentum to the fluid and the lens particles in front of it. On the tip being
Retracted, the fluid cannot follow thereby created a void in front of the tip The
Void is collapsed by the implosion (Cavitation) of the tip thereby creating
Additional shock waves.
39
d.There is an impact of fluid and lens particles being forward in front of the tip.
Considering the mechanism of phaco it is clear that there is attenuation of energy within
nuclear material. This reduces the deleterious effects on the corneal endothelium.
Therefore posterior chamber phacoemulsification helps maintain safety of the procedure
by increasing the working distance from the endothelium.
Phaco parameters:
� Ultrasonic power
The ultrasonic power is usually about 50% to 70%. If the lens is soft, it is decreased to
about 30% and if it is hard, power is increased to 80% to 90%.
� Effective phaco time
It is the total phaco time at 100% phaco power. Effective phaco time is very significant as
less effective phaco time that indicated proportionately less energy delivered to the eye
thereby reducing the side effects of phaco power.
� Phacopower
It is the ability of the phaco hand piece to cut or emulsify cataract. Phacopower is directly
related to stroke length, frequency and efficiency of hand piece.
� Stroke length
Stroke length is the distance by which the titanium phacotip moves to and fro. It is most
important factor in deciding the phacopower. The stroke length can be altered by changing
the phacopower setting of the machine.
40
� Frequency
Frequency is the number of times the tip moves and it is fixed for a particular phaco
handpiece.
It is measured in KHz’s. Power variables are adjusted
intraoperatively depending on
- Density of nucleus where phacotip engaged
- Amount of tip engaged
- Linear velocity of the tip during emulsification.
While too little a power will fail to cut the nucleus, too much power will cause the nucleus
to fly away from the ultrasound tip.
OPERATIVE STEPS
STEP 1- SIDEPORT ENTRY
A beveled paracentesis incision is made at 9.30 position with sideport blade. The
AC is deepened with 2% methyl cellulose or viscoelastics.
STEP 2- CONTINUOUS CURVILINEAR CAPSULORRHEXIS
The ccc is performed through sideport using a bent capsulotomy needle. A 5mm
ccc is acceptable.
STEP 3- CLEAR CORNEAL TUNNEL INCISION
Clear corneal incision is the most commonly used incision for
phacoemulsification with foldable IOL implantation of advantages given below.
41
ADVANTAGES No need of conjuctival flap.
No need of cautry and no bleeding while extending the incision.
Can be performed under topical anaesthesia and takes less time.
Instrumental manipulation is easy.
No distortion of cornea with phaco hand piece and no
compromisation in the view of intraocular structures.
MODIFIED TRIPLANAR OR THREE STEP CORNEAL INCISION
TECHNIQUE
It is made with the help of a very sharp steel keratome 2.8 to 3.2mm in
size.Vertical stab in the cornea at the site of external incision is made with keratome
keeping it perpendicular to cornea. Corneal tunnel is then made with same keratome by
rotating it horizontally and keeping parallel to the corneal lamellae.
INTERNAL CORNEAL INCISION
It is also made with the same keratome by rotating it vertically to make it parallel
to the iris plane resulting in the dimple of corneal surface. The keratome is advanced
anteriorly in the same plane until the AC is entered and the internal wound is visualized as
straight line.
42
FIGURE 4: a) CLEAR CORNEAL INCISION b) SCLERAL TUNNEL INCISION
STEP 4-HYDRODELINEATION
The infusion fluid is injected between the epinucleus and the nucleus. The fluid
wave appears as the golden ring under the surgical microscope. The posterior epinucleus
created by hydrodelineation acts as a cushion safeguarding to a certain extent the posterior
capsule during phacoemulsification. Apart from debulking the nucleus, it also enables the
more realistic use of linear phacoemulsification.
STEP 5- PHACOEMULSIFICATION BY DIVIDE AND CONQUER
Divide and conquer is the most commonly practiced technique for
emulsification. This technique reduces the phaco power and time thus making the
procedure suitable for the beginners.
43
FOUR QUADRANT CRACKING
This method of 4 quadrant cracking is the modification of the technique
originally described by John Sheperd.
Surgery is initiated by moderate amount of sculpting with some trench digging.
Aim is to make the nucleus bear and to create a narrow gulley right down the middle of
the cataract. The trench should be deep as possible and about two phaco tips wide. After
the first trench is made, the nucleus is rotated through 90˚ clockwise direction with the
nucleus rotator inserted through side port incision.
Another tunnel is made in the inferior nucleus similar to the first trench as deep
as possible, beginning the process of quartering the nucleus. After the second trench is dug
the nucleus is rotated another 90̊ clockwise and the third trench is made. The nucleus is
rotated through 90˚ once again and fourth trench is made. It is important that the trenches
are of adequate depth and width as this ensures an easy cracking of the nucleus. After
trenching of the nucleus,it is cracked into four segments. The first segment is engaged and
emulsified by phaco tip followed by other three segments.
STEP 6- IRRIGATION AND ASPIRATION
After the removal of the nucleus, the epinucleus and the cortex are removed by
irrigation and aspiration.
STEP 7-EXTENSION OF PHACO INCISION
The extension is done using a blunt tipped extension keratome.The size of the
keratome should equal the diameter of IOL optic that needs to be implanted through it or
required size for the foldable lens design.
44
STEP 8 -IOL IMPLANTATION
The capsular bagis inflated using viscoelastic followed by implantation of IOL.
Foldable IOL is loaded in the injector with visco. The injector is introduced into the
capsular bag through AC and IOL is injected into the capsular bag.
CLOSING OF PHACO INCISION
The viscoelastic is removed from the AC and in turn is inflated with the
irrigating fluid. The high pressure inside the chamber forces the two lips of internal
opening against each other and closes them. The integrity of the incision should be
checked by depressing the posterior lip of the incision.If the incision is leaking,hydration
of corneal stroma may be tried at the extreme ends of the incision.The corneal edema pulls
the tissue against each other and helps in a leak proof closure. In case the incision still
leaks,a single horizontal 10-0 nylon or vicryl should close the wound.
PROS
2.8 -3.5 mm incision sutureless needed.
Can implant foldable lenses.
Faster can be done in ±10 minutes.
CONS
Difficult with hard nucleus.
Difficult with hyper mature cataract.
Expensive , high maintenance equipment.
45
COMPLICATIONS OF CATARACT SURGERY
INTRAOPERATIVE COMPLICATIONS
ANESTHETIC COMPLICATIONS
Globe perforation and
Retrobulbar haemorrahge.
ANTERIOR SEGMENT COMPLICATIONS43, 44
WOUND RELATED COMPLICATIONS OF MSICS
- Superficial incision leading to button holing of anterior wall
-Deep incision lead to premature entry.
-During side port entry bleeding if made in vascular area, if opening is large –it
may led to increase leaking and shallow AC, Descemet’s detachment, Injury to the iris,
Injury to the lens. Detachment of descemet’s membrane can occur in
MSICS .
COMPLICATIONS RELATED TO ANTERIOR CAPSULOTOMY
Curvilinear capsulorhexis : small rhexis can lead to zonular stress which leads to
zonular dehiscence, avulsion o f bag and PC tears. Large rhexis can lead to difficulties in
placing the IOL in the bag.
Can opener capsulotomy : unequal capsular flaps. The flaps may be aspirated
into the irrigation aspiration cannula. This can cause an inadvertent capsular tear towards
the zonules.
46
COMPLICATIONS DURING HYDROPROCEDURES
Large amount of irrigating fluid is injected. Small radial tears and zonule
ruptures, thus leading to rupture of posterior capsules that will lead to vitreous loss and
posterior dislocation of lens.
COMPLICATIONS DURING NUCLEUS DELIVERY
Inability to prolapse the nucleus may be due to following reason. Small
CCC,Incomplete rotation of nucleus in the bag, small pupil or miosis, can result in zonular
dehiscence.
Dropped nucleus common predisposing factors are – hard nuclear cataract,
small pupil, pseudoexfoliation due to weak zonules. Vitrectomy is indicated in these cases.
COMPLICATION DURING CORTICAL ASPIRATION
Retained lens matter about 25 % usually tend to absorb spontaneously without
any sequelae or complications. But large amount of cortical lens matter can result in
Uveitis, Corneal edema, Secondary glaucoma, Cystoid macular edema
Residual lens matter is usually left behind in following cases Small pupil,
Posterior capsular tears with or without vitreous in AC, small rhexis, subincisional cortex.
POSTERIOR CAPSULAR DEHISCENCE
The most common intra‐operative complication is rupture of the posterior lens
capsule. This is a potentially serious complication due to the associated risk of a dropped
47
nucleus, vitreous loss leading to retinal detachment and cystoid macular oedema and
difficulties with placement of the intraocular lens. From this database, risk factors that
were identified as increasing the risk of posterior capsular rupture were increased age ,
male gender , the presence of glaucoma , diabetic retinopathy , dense cataracts ,
pseudoexfoliation/ phacodonesis , presence of vitreous opacities , small pupil size , axial
lengths of greater than 26.55
The causes of rupture of the posterior capsule usually involve touch of surgical
instruments and can be caused at any stage of the procedure. Capsular block from
excessive hydrodissection can cause a capsular rupture even prior to phacoemulsification.
Other more common causes of capsular rupture are touch from the phacoemulsification
probe or second instruments during the phacoemulsification of the lens or from
irrigation/aspiration instruments during cortical cleanup. Touch from instruments may also
cause an anterior rhexis tear, which can then extend posteriorly to create a posterior
capsular tear. More rare causes of posterior capsular rupture include trauma during
intraocular lens insertion and puncture from loose cannulas during hydration of wounds or
intracameral injections at the conclusion of surgery.
Some types of cataract are also known to have a higher risk of posterior capsular defects.
Congenital posterior polar cataracts have a high incidence of an inherent capsular defect at
the site of the lens opacity and many surgeons perform hydrodelineation rather than
hydrodissection.56 Patients who have had a vitrectomy also face a higher risk either due to
a capsular defect, if lens touch from the vitrector was the cause of the post‐operative
cataract, or because of a floppy, less stable posterior capsule during phacoemulsification
due to the loss of stabilisation from the absence of the vitreous face.
48
The challenges faced by the surgeon following a posterior capsular rupture vary depending
on the stage at which it has occurred. Generally, a rupture that occurs earlier in the case is
much more problematic than one that occurs after the lens and cortex have already been
removed. An early rupture causes difficulties that may necessitate either enlargement of
the corneal/limbal wound to facilitate lens removal, to prevent subsequent dropped nuclear
fragments, if not the whole lens, into the vitreous cavity, which would then require a
vitrectomy. The actual incidence of dropped nuclei is low, at around 0.18 per
cent.57 Despite the psychological trauma of a second operation to both patient and surgeon,
56 per cent of patients will still have a final post‐operative vision of better than 6/12.58 The
timing of vitrectomy and lensectomy should usually be within three weeks
post‐operatively and will depend on factors such as corneal clarity, degree of intraocular
inflammation and intraocular pressure. Early vitrectomy improves visual results, with a
decreased risk of glaucoma, cystoid macular oedema and retinal detachment.59
If the cataract has been removed entirely prior to capsular rupture, disruption of the
vitreous face leads to the presence of vitreous in the anterior chamber. Without adequate
anterior vitrectomy, vitreous strands can lead to destabilisation of the IOL, a peaked pupil,
vitreous through the surgical wound, chronic uveitis and subsequent post‐operative risk of
retinal tears and detachment, cystoid macular oedema and endophthalmitis. Visualisation
of the vitreous can be improved with the use of triamcinolone injected into the anterior
chamber to aid its removal.60
The decision about the position of IOL placement depends on the size of the posterior
capsular defect. If it is a small focal defect, the lens can still be placed carefully in the bag,
made safer if a posterior capsulorrhexis is performed.61 If there is any doubt and definitely
in all cases of a large defect, the IOL needs to be placed in the sulcus. While no optimal
49
IOL exists for sulcus placement in such a situation, the currently available three‐piece
foldable lenses suffice. Prolapsing the optic of the IOL through the anterior rhexis (optic
capture) can help centration and reduce problems such as iris chafing and pigment
dispersion from the square edge of the optic.62
SUPRACHOROIDAL HAEMMORHAGE
Suprachoroidal haemorrhage is very rare with small incision cataract surgery with an
incidence around 0.04 per cent.63 It occurs as the result of sudden rupture of bridging
vessels in the suprachoroidal space and with larger incision cataract surgery and can have
devastating consequences with a sudden intraocular pressure rise leading to expulsion of
ocular contents through the surgical wound. Risk factors for a suprachoroidal haemorrhage
include older age, high intraocular pressure, a history of systemic cardiovascular disease,
systemic hypertension and complicated cataract surgery.64 When it occurs, it is recognised
by sudden shallowing of the anterior chamber and iris prolapse associated with
progressive loss of the red reflex and raised intraocular pressure. Wounds should be
sutured immediately and intraocular pressure lowered with systemic acetazolamide or
mannitol. Experienced surgeons may drain the blood via sclera flaps. The visual outcome
has been reported to be 40 per cent patients achieving 6/12 or better, with another 40 per
cent less than 6/60.63
ZONULAR DEHISCENCE
Capsulorrhexis can be difficult in patients with zonular dehiscence. Depending on
the degree of instability, iris hooks may be required to support the anterior capsule.65 A
capsular tension ring can also be inserted. These are designed to sit at the equator of the
lens within the capsule to provide support by spreading the tension on the zonules. They
are particularly useful in cases of focal zonular loss of less than 180 degrees. In the event
50
of greater than 180 degree loss, techniques such as using a sutured Cionni ring is
desireable. The Cionni ring is similar to a capsular tension ring but is modified with the
addition of one or two eyelets, through which a suture can be placed to stabilise the ring to
the sclera.66 Alternatively, a capsular tension ring segment (Ahmed segment) can be
placed in the bag rather than a full 360‐degree ring. Again, it needs to be sutured to the
sclera. If such a ring or segment is not available, the IOL may be decentred or be unstable
in either the bag or sulcus and an anterior chamber lens may need to be inserted. In the
event that the posterior capsule is not intact, a capsular tension ring is contraindicated.
Any vitreous that has prolapsed through into the anterior chamber must of course be
recognised and removed by anterior vitrectomy. After stabilisation of the capsule and
removal of any vitreous, the IOL can often be safely placed in the bag.
VITREOUS PROLAPSE
Vitreous prolapse is diagnosed by the presence of vitreous in the anterior
chamber (which may occlude the port of the aspirating cannula), distortion of the pupil,
presence of vitreous in the wound and the accompanying posterior capsular rent or zonular
dehiscence while delivery of nucleus.
IRIDODIALYSIS AND IRIS PROLAPSE
Common intraoperative complications seen in manual small incision surgery.
Iridodialysis can happen due to trauma with the instruments while delivering the nucleus.
51
POSTOPERATIVE COMPLICATIONS
COMPLICATIONS RELATED TO INTRAOCULAR LENS
Pupillary capture occurs when port of IOL or whole optic mover anterior to
iris surface to get entrapped pupil.
Decentered IOL this includes - Sunrise syndrome, Sunset syndrome, East-
west syndrome. The variety of syndrome will depend on position at which IOL is
subluxated.
Windshield wiper syndrome in which the IOL moves from side to side with
head movement.
Posterior dislocation of IOL mainly seen intra operatively or immediate or
early postoperatively. But in some cases it can occur in later period also.
Posterior iris shafing syndrome, Erosion and perforation of ciliary body, UGH
syndrome.
SHALLOW AC
Wound leak – In case of MSICS irregular dissection of the tunnel, size of
wound is large and side port entry.
Pupillary block - Pupillary block can occur despite a peripheral iridectomy
which may be lamellar or blocked by vitreous.
Choroidal detachment due to hypotony.
52
IRIS PROLAPSE
Iris prolapse can result from inadequate wound closure, accidental trauma,
or raised intraocular pressure and improper wound construction.
CORNEAL COMPLICATIONS
This is one of most important vision threatening complication seen
postoperatively. This includes – Striate keratopathy which is more common in case of
MSICS,pseudophakic bullous keratopathy corneal decompensation secondary to
endothelial damage or extensive descemet’s detachment intraoperatively.
There is a degree of corneal endothelial cell loss after cataract surgery of around
five to eight per cent. Risk factors include a shorter axial length and longer
phacoemulsification time.67.68 Corneal decompensation following cataract surgery is more
common in those patients with pre‐existing endothelial cell dysfunction, such as in Fuchs'
endothelial dystrophy, where the remaining endothelial cell function post‐operatively may
not be sufficient to keep the cornea clear, thus causing decompensation, oedema and
corneal thickening. To try to avoid this situation, it is important to avoid excessive
phacoemulsification power during cataract surgery and to use a combination of a
dispersive viscoelastic and a cohesive viscoelastic , coined the ‘soft shell technique’.69,70
IRITIS
Inflammation of uveal tissue commonly occurs secondary to increase
handling of uveal tissue, viscoelastics in AC, if cortical wash is incomplete,in case of PC
tear with vitreous loss.
53
HYPHEMA
Common source of blood in anterior chamber includes – Bleeding from
wound, trauma to iris, expulsion hemorrhage. Intraoperative increase handling of iris or
instrumental trauma of uveal tissue can lead to hyphema postoperatively.
RAISED INTRAOCULAR PRESSURE/SECONDARY GLAUCOMA
Immediate rise in IOP postoperatively may due to many reasons –.The most
crucial is the viscoelastic materials used during surgery are incompletely aspirated from
the eye .71 Higher molecular weight viscoelastics have been shown to result in a higher
rise in post‐operative IOP. This can be avoided by administering oral acetazolamide or
topical pressure‐lowering agents in the immediate and early post‐operative period.72
Other causes of ocular hypertension after cataract surgery include pigment dispersion
secondary to sulcus placement of the intraocular,62 presence of air bubble in anterior
chamber, pupillary block glaucoma due to vitreous, uveitis secondary to retained cortical
matter, suprachoroidal hemorrhage with shallow AC, malignant glaucoma and steroid
responders who develop raised IOP secondary to post‐operative steroid eye‐drops.
HYPOTONY
Important causes leading to decrease in intraocular pressure are – wound leak,
choroidal detachment, retinal detachment.
POSTERIOR CAPSULAR OPACIFICATION
Posterior capsular opacification (PCO) is the most common post‐operative
complication of cataract surgery. Residual lens epithelial cells are inevitably left at surgery
in the equatorial capsular bag. Migration of lens epithelial cells to the posterior capsule
54
can cause increasing opacity impairing the vision of the patient, with a fall in visual acuity
and contrast sensitivity.73,74 Risk factors include younger age, uveitis and ocular
inflammation or diseases such as retinitis pigmentosa. Aclinical research shows that a
square IOL edge inhibits lens epithelial cell migration to the posterior capsule.75-77 In the
event of the development of post‐operative posterior capsular opacification, the treatment
is a capsulotomy using an Nd:YAG laser. Posterior capsular opacification should be
visually significant if there is a subjective and objective decrease in vision consistent with
the degree of posterior capsular opacification noted on slitlamp examination. Rates of
YAG capsulotomies in pseudophakes up to 20.4 per cent are reported.78 Reported risks of
YAG capsulotomy include short‐term intraocular pressure rise, subluxation of the IOL and
increased risk of cystoid macula oedema.79 Thus, most people prefer not to perform YAG
capsulotomies earlier than three months post‐operatively. An increased risk of retinal tears
and detachment is more controversial. The risk is probably higher in young patients and
high myopes who already have a generally higher risk of retinal detachment than the
normal population.80 While the exact mechanism of how a YAG capsulotomy may be
related to a retinal tear or hole is uncertain, it possibly involves disruption to the
vitreous.79 A hole or tear may be caused by anterior vitreous detachment during
phacoemulsification, followed by a forward displacement of the vitreous as the result of
the capsulotomy.80
55
POSTERIOR SEGMENT COMPLICATIONS
CYSTOID MACULAR EDEMA
Cystoid macular oedema commonly occurs 1 to 3 months after cataract
surgery. It is also termed as Irvine‐Gass syndrome. Cystoid macular oedema occurs as a
result of leakage of fluid into the macula from perifoveal retinal capillaries and this
Intraretinal fluid accumulates in the outer plexiform and inner nuclear layers forming
cystic spaces. Cystoid macular oedema typically presents as a reduction in visual acuity
(usually down to 6/18 or 6/24), possibly with distortion a few weeks after surgery. It
occurs after about two per cent of uncomplicated procedures, although asymptomatic
cystoid macular oedema demonstrable on fluorescein angiography may have a much
higher incidence.81 Risk factors include diabetes, uveitis, previous retinal vein occlusion,
epitretinal membrane, use of topical prostaglandin analogues,exposure to UV rays and
vitreous traction , posterior capsular rupture with vitreous loss, and cystoid macular
oedema following fellow eye surgery.82 Studies have shown that use of peri‐operative
topical non‐steroidal anti‐inflammatory (NSAID) medication can lower the incidence of
pseudophakic cystoid macular oedema..
The advent of optical coherence tomography (OCT) has allowed accurate, non‐invasive
assessment of macular morphology, and hence facilitates the diagnosis of cystoid macular
oedema. Interestingly, OCT studies have shown that even in non‐clinical cystoid macular
oedema eyes, an asymptomatic increase in macular thickness can be shown at 12 weeks
after surgery. Fluorescein angiography in cystoid macular oedema gives a classic ‘flower
petal’ appearance as dye accumulates in cystic spaces in the outer plexiform layer,
radiating from the foveal centre.
56
The condition will usually resolve spontaneously and it has been shown that topical
steroids and NSAIDS may hasten this resolution.82 If topical treatment fails, intravitreal
steroids may be injected to bring about resolution. The overall prognosis is good, with
more than per cent of cases resolving over two years.
CHOROIDAL DETACHMENT
Postoperative choroidal detachment can occur at three stages. Immediately
after surgery, 7-21 days after surgery, months – year after surgery.
RETINAL DETACHMENT
Postoperative retinal detachment is common in aphakics then in
pseudophakics. Presence of vitreous loss intraoperatively, patient of high myopia with
predisposing retinal degeneration, retinal break/tear in fellow eye, retention of lens
fragment, dislocation of IOL, YAG laser capsulotomy are the risk factors for retinal
detachment. A cumulative risk of about 0.9 per cent four years after surgery has been
reported, with the risk increasing each year after surgery. One study reported that the
increased risk persisted for at least six years and that the overall cumulative eight‐year
incidence of retinal detachment was increased by almost nine‐fold in operated eyes.
Intra‐operative events such as a posterior capsular tear and zonular dehiscence increase the
risk. and dislocation of nuclear fragments into the vitreous increases the risk further.
VITREOUS OPACIFICATION
Due to vitreous hemorrhage, posterior uveitis or advanced asteroid
hyalosis can lead to decreased visual acuity.
57
INFECTIOUS ENDOPHTHALMITIS
Endophthalmitis is one of the most feared complications of cataract surgery
due to its devastating consequences. The most common risk factors are posterior capsular
rupture, prolonged surgical time, wound leak and less experienced surgeons.The reported
incidence of endophthalmitis after cataract extraction is in the range of 0.05 to 0.5%.
Infectious endophthalmitis most commonly occurs due to intraocular microbial
contamination from the patient’s skin, preocular tear film and ocular adnexa. The
commonly isolated organisms are staphylococcus epidermidis, staphylococcus aureus,
streptococcus species followed by gram negative bacteria.
Endophthalmitis can present either acutely or as a chronic form. Acute
cases occur within days of surgery and present with pain, redness, marked anterior
chamber cells, hypopyon and vitritis, and are most commonly caused by gram‐positive
organisms (93 per cent in total, 49 per cent of which are coagulase‐negative staphylococci)
and typically originate from the patient's lid flora. Chronic cases can occur many weeks
later and can present as persistent inflammation. Prompt diagnosis is vital with an anterior
chamber tap and vitreous biopsy, with or without a core vitrectomy. Acute treatment
consists of intravitreal antibiotics, usually ceftazidime and vancomycin and primary
vitrectomy depending on the severity of the case. In chronic cases (more than six weeks
after surgery), Proprioniobacterium acnes must be considered as a cause of chronic
inflammation. A fluffy white posterior capsular plaque is classically seen, as it is thought
that the organism sequesters between the capsule and IOL. Apart from intravitreal
antibiotics (usually vancomycin) and vitrectomy, a capsulectomy with or without IOL
extraction may be required.83,84
58
Currently, the three most accepted methods of reducing the risk are to use an
appropriate antiseptic solution (povodone‐iodine), adequate draping of the surgical field to
exclude the eyelashes and the use of intracameral antibiotics, such as cefuroxime at the
conclusion of surgery. The European Society of Cataract and Refractive Surgeons
(ESCRS) study demonstrated that a single dose of 1mL of intracameral cefuroxime at the
conclusion of surgery reduced the risk of endophthalmitis by a factor of almost five, from
down to 0.07 percent. Majority of surgeons use topical fourth generation
fluoroquinolones (gatifloxacin or moxifloxacin) one to three days pre‐operatively rather
than intracameral antibiotics, with most surgeons citing concerns regarding the lack of
commercially available antibiotic for intracameral use.
OTHER SIMILAR STUDIES
Gogate et al8 compared phacoemulsification vs MSICS by randomization in
terms of safety, efficacy and astigmatic change. From his study he concluded that at 1st
week 61.25% in MSICS group and 68.2% patients in phacoemulsification group had
UCVA of better than or equal to 6/18.At 6th week 81.08% and 71.1% in phaco and
MSICS had UCVA of better than or equal to 6/18. From this study he concluded that both
phacoemulsification and MSICS are equally safe and achieved excelled visual outcomes
following cataract surgery.
Singh et al9compared MSICS vs. phaco terms of safety and efficacy in immature
cataract patients. On 1st post operative day more than 2/3rds of the patient in the phaco
group and more than three quarters of the patient in the SICS group had good visual
outcome stating that SICS is an apt pr ocedure for immature cataracts.
Venkatesh et al5 compared white cataracts by randomization. He concluded that
MSICS and phacoemulsification achieved excellent visual outcome with low complication
59
rates. But MSICS being faster and less technology dependent, cost effective than
phacoemulsification It is proved to be an alternative in the developing countries for mature
cataract.
Cook et al10 compared visual outcome with equal number of patients by
randomisation. On day 1, visual outcomes were equal in both the groups. After 8 weeks
the CVA and UCVA were better in phaco than MSICS .He concluded that MSICS is an
acceptable alternative to phaco in developing and under developed countries
61
METHODOLOGY
On approval from ethical committee,a non randomized comparative study was
conducted.Patients with the age of above 50 years with unilateral or bilateral cataract are
selected and examined. Non randomization was done on patients preference for surgery.
Written informed consent was obtained from the patients who were selected for the
procedure. Detailed history was taken. Visual acuity was assessed with snellen’s chart.
Anterior segment evaluation was done by slit lamp. Fundoscopy was done using 78D lens
and indirect ophthalmoscope to assess posterior segment pathology.
Basic routine investigations like RBS, SEROLOGY were done.
A SCAN biometry was done to measure the IOL power.
B SCAN was done in mature cataract.
IOP was measured using Non-contact tonometry or applanation tonometry.
Keratometry values were taken with baush and laumb and finally lacrimal syringing was
done.
Written informed consent will be taken once surgery is planned. Patients were followed
on 1st week, 2nd week and 6th week subsequently post-operatively. Visual acuity, slit-
lamp examination, refraction and fundus examination were done at each visit.
INCLUSION CRITERIA
Patients willing to give consent.
Patients above 50 years of age belonging to either sex.
Patients with no corneal pathology.
Patients with no posterior segment pathology.
62
EXCLUSION CRITERIA
Patient not willing to give consent.
Patients who are unable to attend the follow-up visits.
Patients with co-existing glaucoma, corneal pathology, uveitis, poor pupil dilation
(5.0 mm), and other known pathology that could impair visual outcome.
Patients with subluxated and traumatic cataract, complicated cataract
STATISTICS
The data collected will be analysed statistically using descriptive statistics. The analysis
will be done by using spss version 21.The suitable statistical test will be conducted. The
collected data were analyzed with IBM.SPSS statistics software 23.0 version. To describe
about the data descriptive statistics frequency analysis, percentage analysis were used for
categorical variables and the mean & S.D were used for continuous variables. To find the
significance in categorical data Chi-Square test and T test was used. In the above statistical
tool the probability value .05 is considered as significant level.
SAMPLE SIZE ESTIMATION
A total of 200 patients with cataract (mature, immature and hyper mature cataract)
attending the ophthalmology OPD at RRMCH from November 2017 to October 2018 will
be taken for study. Since this was an hospital based study, sample size was calculated by
taking the average of the patients with cataract who have undergone operation for the past
three years fulfilling the inclusion criteria and exclusion criteria.
MATERIAL AND METHODS
SOURCE OF DATA
The study will be conducted in patients who will be undergoing phacoemulsification and
small incision cataract surgery, in the department of ophthalmology, in Rajarajeswari
medical college, Bangalore.
METHOD OF COLLECTION OF DATA
A non randomised comparative study will be conducted on patients who have undergone
phacoemulsification and small incision cataract surgery during the period of one year
(from November 2017 to October 2018) fulfilling the inclusion/exclusion criteria in the
department of ophthalmology in Rajarajeswari medical college, Bangalore.
SAMPLING METHOD
Purposive sampling method.
.
STUDY DESIGN
Non randomised comparative study
60
63
PHACOEMULSIFICATION MSICS
80
60
40
20
0
100 100
120
100
TYPE OF SURGERY
RESULTS
A total of 200 cases were selected for the study, out of which 100 patients underwent
MSICS and 100 patients underwent phacoemulsification. Their distribution was done by
non-randomisation method based on the patient’s preference to surgery.
TABLE 1: TYPES OF SURGERY
TYPES OF SURGERY FREQUENCY PERCENT
MSICS
PHACO
TOTAL
100
100
200
50
50
100
FIGURE 5-TYPES OF SURGERY
64
51-60 61-70 71-80 81-90
2 3
12
MSICS
PHACO 15
35
43 43
47 50
45
40
35
30
25
20
15
10
5
0
TABLE 2: AGE DISTRIBUTION
ITEMS
TYPES OF
SURGERY
Total
Chi Square
Value
Sig Value
Result
MSICS PHACO
AGE
51-60 47 43 90
1.532
0.675
STATISTICALLY
NOT
SIGNIFICANT
61-70 35 43 78
71-80 15 12 27
81-90 3 2 5
The majority of patients who underwent cataract surgery were in the age group of 51-60.
Since the p value was 0.675, there were no significant association between age and type of
surgery.
FIGURE 6- AGE DISTRIBUTION
65
FEMALE MALE
40 60
PHACO
MSICS
47
80
60
40
20
0
53
120
100
TABLE: 3 GENDER DISTRIBUTION
ITEMS
TYPES OF
SURGERY
Total
Chi Square
Value
Sig Value
Result
MSICS PHACO
GENDER
Female 60 53 113
0.997
0.318 Null Hypothesis
Accepted Male 40 47 87
The total male and female ratio was 87:113. In MSICS sex ratio was 40:60.In
phacoemulsification sex ratio was 47:53.Here the p value was not significant (0.318)
hence there was no significant association between gender and type of surgery.
FIGURE 7 – GENDER DISTRIBUTION
66
LEFT EYE RIGHT EYE
58 42
PHACO
MSICS
53 47
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
TABLE 4: LATERALITY
ITEMS
TYPES OF
SURGERY
Total
Chi Square
Value
Sig Value
Result
MSICS PHACO
EYE L/R
Left Eye 42 47 89
0.506
0.318
STATISTICALLY
NOT
SIGNIFICANT
Right Eye
58
53
111
Right eye was the most commonly operated eye in both MSICS and
phacoemulsification.The p value was not significant (0.318) and so there was no
significant association between laterality and type of surgery.
FIGURE 8 – LATERALITY
67
6/24 -6/18 6/60 -6/24 CF PL PR &
HMCF
MSICS
PHACO 11
15
22
27 27
31 31
36 40
35
30
25
20
15
10
5
0
TABLE 5: PRE-OPERATIVE VISUAL ACUITY
ITEMS
TYPES OF
SURGERY
Total
Chi Square
Value
Sig Value
Result
MSICS PHACO
PREOPERATIVE Vision
6/24 - 6/18 11 15 26
2.517
0.472
STATISTICALLY
NOT
SIGNIFICANT
6/60 - 6/24 31 36 67
CF 27 27 54
PLPR &
HMCF 31 22 53
Total 100 100 200
Majority of the patients had pre-operative visual acuity ranging from 6/60-6/24 in both
phacoemulsification. The p value was 0.472 stating no signification association between
pre-operative visual acuity and type of surgery.
FIGURE 9 – PRE-OPERATIVE VISUAL ACUITY
68
PHACO MSICS
Less than 6/60
6/18 - 6/60
Better than 6/18 17 10 12
46 42
POST OPERATIVE VISION -1ST WEEK
73
TABLE 6: UNCORRECTED POST-OPERATIVE VISUAL ACUITY AT 1ST
WEEK
POST OPERATIVE VISION
TYPES OF
SURGERY
Total
MSICS PHACO
1ST Week
Less than 6/60 12 10 22
6/18 - 6/60 42 17 59
Better than 6/18 46 73 119
POST OPERATIVE
VISION
t-test for Equality of Means
t
Df
Sig. (2-
tailed)
Result
1st Week -3.046 198 .003 Statistically
Significant
At 1st post-operative week, in the MSICS group 46 % of parients had vision better than
6/18 whereas in the phaco group it was 73% of patients with the same vision.42% and
17% of patients in the MSICS group and in the phaco group had a V/A of 6/18-6/60.only
12% in MSICS group and 10% in phaco group had V/A of <6/60.The p value (.003) was
< 0.05. So there was a significant difference between two surgeries at the 1st post-
operative week.
FIGURE10 - UNCORRECTED POST-OPERATIVE V/A 1ST WEEK
69
Less than 6/18 - 6/60 Better than
6/60 6/18
14 2 0
MSICS
PHACO
39
61
84 100
80
60
40
20
0
POST OPERATIVE VISION -2nd WEEK
TABLE 7: UN CORRECTED POST OPERATIVE VISUAL ACUITY AT 2ND
WEEK
POST OPERATIVE VISION
TYPES OF SURGERY
Total
MSICS PHACO
2ND WEEK
Less than 6/60 0 2 2
6/18 - 6/60 39 14 53
Better than 6/18 61 84 145
POST OPERATIVE
VISION
t-test for Equality of Means
t
Df
Sig. (2-
tailed)
Result
2ND WEEK -3.203 198 .002 Statistically
Significant
At post – operative 2nd week, 61% of patients had visual acuity of better than 6/18in the
MSICS group.But in the phaco group 84% of patients had the same vision.39% and 14%
of patients had a visual acuity of 6/18-6/60..no patients in the MSICS group had vision of
<6/60 whereas only 2% had visual acuity of<6/60.Here the p value was 0.002.So they
were statistically significant.
FIGURE 11 – UNCORRECTED POST OPERATIVE V/A 2ND WEEK
70
Better than
6/18
Less than 6/60 6/18 - 6/60 0
5 2 0 20
MSICS
PHACO 26
60
40
74 80
93 100
POST OPERATIVE VISION -6th WEEK
TABLE 8: UNCORRECTED POST –OPERATIVE VISUAL ACUITY AT 6TH
WEEK
POST OPERATIVE VISION
TYPES OF SURGERY
Total
MSICS PHACO
6TH WEEK
Less than 6/60 0 2 2
6/18 - 6/60 26 5 31
Better than 6/18 74 93 167
POST OPERATIVE
VISION
t-test for Equality of Means
t
df
Sig. (2-
tailed)
Result
6TH WEEK -3.017 198 .003 Statistically
Significant
Nearly 74% and 93% in MSICS and phaco group had a vision of >6/18. 26% of patients
had visual acuity of 6/18-6/60 and only 5% 0f patients had the same V/A. But the V/A of
2% patients in the phaco group deteriorated. Here the p value was < 0.05.Hence they were
statistically significant.
FIGURE 12 -:UNCORRECTED POST –OPERATIVE V/A 6TH WEEK
71
6/18 - 6/60 Better than 6/18
Less than
6/60
0 0 2 2 0
20
MSICS
PHACO
100
80
60
40
POST OPERATIVE VISION -BCVA AT END OF 6
WEEKS
98 98
TABLE 9: BEST CORRECTED VISUAL ACUITY AT THE END OF 6 WEEKS
POST OPERATIVE VISION
TYPES OF SURGERY
Total MSICS PHACO
BCVA AT
END OF 6
WEEKS
Less than 6/60 0 2 2
6/18 - 6/60 2 0 2
Better than 6/18 98 98 196
POST OPERATIVE
VISION
t-test for Equality of Means
t
Df
Sig. (2-
tailed)
Result
BCVA AT END OF 6
WEEKS
0.636
198
.526 Statistically
Not Significant
At the end of 6 weeks, the best corrected visual acuity improved in all the patients 98 % in
both MSICS and in phaco group. 2% of patients had vision of 6/18-6/60 in MSICS group
who had resolving CME. But 2% of patients in the phaco group had visual acuity of<
6/60.In these patients corneal edema occurred post operatively and not subsided even at
the end of 6th week. The p value here was < 0.05.So they were not statistically significant.
FIGURE 13 - BCVA AT THE END OF 6 WEEKS
72
TABLE 10: TYPE OF SURGERY vs ASTIGMATISM
Cross tabulation
TYPES OF SURGERY
ASTIGMATISM
Total
ATR Nil WTR
MSICS 79 9 12 100
PHACO 38 62 0 100
Total 117 71 12 200
Here in this table 79% and 12% of patients had against the rule astigmatism and with the
rule astigmatism respectively. Rest of the patients 9% had no astigmatism.Whereas in the
phaco group 38% of patients had against the rule astigmatism and the remaining patients
had no astigmatism at the end of 6 weeks.
73
WTR Nil
ASTIGMATISM
ATR
12 9
79 90
80
70
60
50
40
30
20
10
0
ASTIGMATISM VS SURGERY - MSICS
WTR Nil
ASTIGMATISM
ATR
0
10
0
38
50
40
30
20
62 70
60
ASTIGMATISM VS SURGERY - PHACO
FIGURE 14 -MSICS vs SIA
FIGURE15-PHACOEMULSIFICATION vs SIA
74
Below - -0.50 to - -1.00 to - -1.50 to -
0.50 1.00 1.50 2.00
TYPES OF SURGERY PHACO
TYPES OF SURGERY MSICS
55
11 31
3
86 80%
60%
40%
20%
0%
2 12
0 100%
Refraction VS Types of Surgery
TABLE 11: REFRACTION vs TYPE OF SURGERY
RERACTION * TYPES OF SURGERY Cross tabulation
RERACTION TYPES OF SURGERY
Total MSICS PHACO
Below -0.50 55 86 141
-0.50 to -1.00 31 14 43
>-1.00 to -1.50 11 0 13
>-1.50 to -2.00 3 0 3
Total 100 100 200
55% of patients had no astigmatism/minimal astigmatism of <- 0.5 in the MSICS group
whereas in the phaco group it was 86%.Astigmatism of -0.5 to -1.00 diopters were
acquired by 31% and 14% in the MSICS and phaco group respectively.11% and 3% of
patients in MSICS group had astigmatism of >-1 to -1.50 and >-1.50 – 2.00 diopters.
FIGURE 16 – POST OPERATIVE REFRACTION AT THE END OF 6 WEEKS vs
TYPE OF SURGERY
75
MSICS 0 0
PHACO 2 1 96
1 1 1
2 1 95
0 100% 90% 80% 70% 60% 50% 40% 30% 20% 10%
0%
TABLE 12 : INTRAOPERATIVE COMPLICATIONS VS TYPES OF SURGERY
COMPLICATIONS
TYPES OF SURGERY
Total
MSICS PHACO
DM Detachment 0 1 1
Irido Dialysis With Corneal Edema 1 0 1
Nil 96 95 191
Pcr With Vitreous Loss 1 1 2
Pcr Without Vitreous Loss 2 2 4
Phaco Burns 0 1 1
Total 100 100 200
FIGURE 17- INTRAOPERATIVE COMPLICATIONS VS TYPES OF SURGERY
76
STRIATE
KERATOPATHY
NIL 89
CORNEAL EDEMA
HYPHEMA
IRIS PROLAPSE
1 2 2 2 31
CME
ANTERIOR UVEITIS MSICS
TABLE 13 :POST OPERATIVE COMPLICATIONS * TYPES OF SURGERY
Crosstabulation
COMPLICATIONS TYPES OF SURGERY Total
MSICS PHACO
Anterior Uveitis 2 3 5
Cme 2 0 2
Corneal Edema 3 3 6
Hyphema 1 0 1
Iris Prolapse 1 0 1
Nil 89 92 181
Striate Keratopathy 2 2 4
Total 100 100 200
The most common intraoperative complications were posterior capsular rent without
vitreous loss (2%) in both the groups. Majority of the patients had no complications during
surgery.
FIGURE 18- POST OPERATIVE COMPLICATIONS (MSICS)
77
STRIATE
KERATOPATHY
NIL
IRIS PROLAPSE 92
HYPHEMA
CORNEAL EDEMA 3
CME 0 30 0 2
PHACOEMULSIFICATION
ANTERIOR UVEITIS
The most common post operative complications in MSICS group were corneal edema
(3%),anterior uveitis (2%),striate keratopathy(2%),CME (2%).
FIGURE 19 –POST OPERATIVE COMPLICATIONS (PHACO)
The most common post operative complications in phaco group were as follows: corneal
edema (3%),anterior uveitis (3%),striate keratopathy(2%) Total number of patients with
no complications were almost equal in MSICS group(89%) and in phaco group (92%).
78
DISCUSSION
We selected 200 patients with cataract irrespective of type of cataract with no
other ocular pathology. Equal number of patients were enrolled into both MSICS group
and phaco group by non randomisation. They were distributed based on their preference
to surgery. Patients were followed at 1st week, 2nd week and at the end of 6th week. We
compared the UCVA during their follow up visits and BCVA at the end of 6th week. We
also compared complications and surgically induced astigmatism following MSICS and
phacoemulsification.
AGE AND GENDER DISTRIBUTION
In our study, the most common age group was 51-60.The sex ratio was 113
:87.Females being more than males. Patients got operated for right eye more than the left
eye.The most common pre-operative visual acuity range was 6/60-6/24.
Ramalakshmi et al 85 selected 100 patients for the study; 40 underwent
phacoemulsification with PCIOL and 60 underwent MSICS. In phacoemusification group,
most of the patients were in the age group < 50 years of age and in MSICS group most of
the patients were in the age group of 50-60 years. In phacoemulsification group, 25 were
females and 15 were males. In MSICS group, 30 were females and 30 were males .
In a study conducted by Mahayana et al, 583 (51.3%) eyes received mSICS and
554 (48,7%) eyes received phacoemulsification. There were no differences in age and sex
between the 2 groups, in which 602 (52.9%) were men and 535 (47.1%) were women.
Singh et al9 compared the safety and efficacy of phacoemulsification and SICS in
immature cataract. A prospective randomized controlled trial was carried out involving 93
and 89 patients with immature senile cataract selected for phacoemulsification and SICS
79
respectively There was no difference between the groups in terms of gender, age and pre-
operative visual acuity (p = 0.09).
Cook et al10 showed the participant baseline demographic characteristics in his
study. There was no difference between the 2 groups.
POST-OPERATIVE UNCORRECTED VISUAL ACUITY AT 1ST WEEK
At 1st week, 46% of patients had uncorrected visual acuity of >6/18 in the
MSICS group and 73% in the phaco group. 42% and 17% of patients had visual acuity of
6/18-6/60 in the MSICS and phaco group.
Venkatesh et al5 compared the safety and efficacy of phacoemulsification and
manual small-incision cataract surgery (SICS) to treat white cataracts in southern india.
Consecutive patients with white cataract were randomly assigned to have
phacoemulsification or manual SICS . Surgical complications, operative time, uncorrected
(UDVA) and corrected (CDVA) distance visual acuities, an On the first postoperative day,
the UDVA was comparable in the 2 groups (P = .805).
Singh et al9 showed in his study that In phacoemulsification group (n=93)
more than two thirds and in SICS group (n=89) more than three quarters of the patients
had good visual outcome (6/6-6/18) on first postoperative day (p=0.065). Poor outcome
(<6/60) was recorded in 6% (phacoemulsification group) and 1% (small incision cataract
surgery group).
Gogate et al 8compared the efficacy, safety, and astigmatic change after
Cataract surgery by phacoemulsification and MSICS via a randomized control trial. The
authors found that at week 1, there were 68.2% patients in the phacoemulsification group
and 61.25% patients in the SICS group that had UCVA better than or equal to 6/18.
80
In a study by cook et al10 there was no difference in the visual acuities at
the post-operative 1st week.
POST-OPERATIVE UNCORRECTED VISUAL ACUITY AT 2ND WEEK
At 2nd week, the uncorrected visual acuity of >6/18 was achieved by 61% in
the MSICS group and 84% in the phaco group.39% of patients had visual acuity of 6/18-
6/60 in the MSICS group and it was 14% in the phaco group.
POST-OPERATIVE UNCORRECTEDVISUAL ACUITY AT 6TH WEEK
At the end of 6 week,74% patients achieved >6/18 uncorrected vision in the
MSICS group and majority of the patients 93% achived the same vision in the phaco
group. The best corrected visual acuity achieved was 98% in both the groups.But 2% of
patients achieved vision of 6/18-6/60 in the MSICS group and 2% achived <6/60 in the
phaco group.
In a study by venkatesh et al, at 6 weeks, the UDVA was 20/60 or better in 99
patients (87.6%) in the phacoemulsification group and 96 patients (82.0%) in the manual
SICS group (P = .10) and the CDVA was 20/60 or better in 112 (99.0%) and 115 (98.2%),
respectively (P = .59).
Gogate et al8 in his study showed that at 6 weeks follow up, 81.08% patients in
the phacoemulsification group and 71.1% patients in the SICS group had UCVA of better
than or equal to 6/18.
Cook et al10 showed that the uncorrected and the corrected visual acuities were
better in the phaco-emulsification group than the SICS group aqt the end of 8th week.
Ramalakshmi et al85 found that on the 40th day post-operative follow-up visit, 92
out of 96 patients had visual acuity (VA) ≥6/18 and the other 4 had deteriorated vision in
both groups.
81
COMPLICATIONS
The most common intraoperative complication was PCR without vitreous
loss(2%) in both the groups. Majority of the patients had no intraoperative complications.
In MSICS the most common post operative complications were corneal edema
(3%),anterior uveitis (2%),striate keratopathy(2%),CME (2%). The most common
complications in phaco group were corneal edema (3%),anterior uveitis (3%),striate
keratopathy(2%).Total number of patients with no post operative complications were
almost equal in MSICS group(89%) and in phaco group (92%).
In a study conducted venkatesh et al5 and the manual SICS group had less corneal
edema (10.2%) than the phacoemulsification group (18.7%) (P = .047). Posterior capsule
rupture occurred in 3 eyes (2.2%) in the phacoemulsification group and 2 eyes (1.4%) in
the manual SICS group (P = .681).
Cook et al10 in his study found that more eyes in the phaco-emulsification group
had corneal oedema compared with the manual small-incision group on day 1 (35 v. 29),
but this difference was not significant (p=0.36).
Ramalakshmi et al 85found that in the phacoemulsification group, 2 cases out of
40 had intraoperative complications, and in the manual phacoemulsification group, 6 out
of 60 cases had intra- and post-operative complications in the form of corneal edema,
posterior capsular rent, and zonular dialysis. Hence, in this study, phacoemulsification
group produced fewer complications than the MSICS group .
82
SURGICALLY INDUCED ASTIGMATISM
Patients with against the rule astigmatism accounted for 79% and with the rule
astigmatism accounted for12% in the MSICS group. Rest of the patients 9% had no
astigmatism. Whereas in the phaco group 38% of patients had against the rule astigmatism
and the remaining patients had no astigmatism at the end of 6 weeks.
55% of patients had no astigmatism/minimal astigmatism of <- 0.5D in the
MSICS group whereas in the phaco group it was 86%.Astigmatism of -0.5 to -1.00 D were
acquired by 31% and 14% in the MSICS and phaco group respectively.11% and 3% of
patients in MSICS group had astigmatism of >-1 to -1.50 and >-1.50 – 2.00 D.
Cook et al 10 in his sudy showed that there was less astigmatism in the phaco-
emulsification group at the end of 8th week post-opratively.
Ramalakshmi et al85 study showed that the Induced astigmatism in the 40th day
and 6th month follow-up was comparatively less in phacoemulsification than SICS.
DISADVANTAGES
1. All eyes in the phacoemulsification group had a foldable IOL implanted where as
eyes that underwent MSICS had rigid IOL implantation. This difference in the types of
IOL used might have influenced postoperative visual function to some extent.
2. In our study no attempt was made to correct the pre-existing cylinder
intraoperatively.
83
ADVANTAGES
1. The main advantage in our study was patients were distributed by non
randomization method. Distribution was done based on the patients preference to
the surgery.
2. The sample size was quite a decent number to assess the visual outcome and
complications.
3. They were followed on three different weeks 1st week ,2nd week and 6th week.so
their visual outcome progress was witnessed.
84
CONCLUSION
The uncorrected visual acuity in the immediate post- operative week was
excellent in phaco group compared to MSICS group. But in the ealy and late post-
opetrative weeks, the uncorrected visual acuity in the MSICS group improved to a great
extent. But still phacoemulsification group excelled in achieving good vision.
The best corrected visual acuity was equal in both the groups at the end of 6th
week. MSICS induced more astigmatism than phacoemulsification post-operatively which
was corrected later to obtain the equal percentage of patients with good vision at the end
of 6 weeks as that of phacoemulsification group. The amount of astigmatism obtained by
the phaco group was minimal compared to MSICS group.
The complication rates were almost equal in both the groups.But 2% of patients
had low vision in the phaco group due to unresolved corneal edema which progressed to
corneal decompensation.
Both the surgeries had low complication rates in my study. But
phacoemulsification had better visual outcome than MSICS in all the weeks.MSICS being
cost effective,low technology dependent and less learning curve needed can be accepted as
an alternative to phacoemulsification in developing countries like India.
85
SUMMARY
In Our study most of the patients belonged to 51-60 age category.
There were female preponderance over male.
Right eye was the most commonly operated eye in both the groups.
Most of the patients in the study had a visual acuity from 6/60 to 6/18.
At 1st post operative week visual outcome was excellent in phaco group.
In MSICS group ,visual acuity improved at 2nd and 6th post-operative weeks. In
phaco 2% of patients had low vision due to unresolved corneal edema.
Surgically induced astigmatism was higher in MSICS group than the phaco group.
The best corrected visual acuity was same in both the groups at the end of 6 weeks.
The complication rates were almost equal in both the groups with no undue
advantage.
86
REFERENCES
1. Comparing different techniques of removing cataracts | Cochrane [Internet]. [cited
2017 Oct 18]. Available from: /CD008813/EYES_comparing-two-different-techniques-of-
removing-cataracts.
2. Ang M, Evans JR, Mehta JS. Manual small incision cataract surgery (MSICS) with
posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with
posterior chamber intraocular lens for age-related cataract. Cochrane Database Syst Rev.
2012;4:CD008811.
3. Ellant JP, Obstbaum SA. Lens-induced glaucoma. Doc Ophthalmol. 1992;81(3):317–
38.
4. Tabin G, Chen M, Espandar L. Cataract surgery for the developing world. Curr Opin
Ophthalmol. 2008 Jan;19(1):55–9.
5. Daien V, Le Pape A, Heve D, Carriere I, Villain M. Incidence and Characteristics of
Cataract Surgery in France from 2009 to 2012: A National Population Study.
Ophthalmology. 2015 Aug;122(8):1633–8.
6. Congdon N, Taylor H. Chapter 8: Age related cataract. Arnold Publishers, 2003.
7. Dolin P. Chapter 5: Epidemiology of cataract. Chapman & Hall Medical, 1998.
8. Hammond CJ, Duncan DD, Snieder H, de Lange M, West SK, Spector TD, Gilbert CE.
The heritability of age-related cortical cataract: the twin eye study. Invest Ophthalmol Vis
Sci 2001;42:601-5.
87
9. Hammond CJ, Snieder H, Spector TD, Gilbert CE. Genetic and environmental factors in
age-related nuclear cataracts in monozygotic and dizygotic twins. N Engl J Med
2000;342:1786-90.
10. Jaggernath J, Gogate P, Moodley V, Naidoo K. Comparison of cataract surgery
techniques: Safety, efficacy, and cost-effectiveness. Eur J Ophthalmol. 2013 Dec 13;24:0.
11. Venkatesh R, Tan CSH, Sengupta S, Ravindran RD, Krishnan KT, Chang DF.
Phacoemulsification versus manual small-incision cataract surgery for white cataract. J
Cataract Refract Surg. 2010 Nov 1;36(11):1849–54. 10.Congdon N, Taylor H. Chapter 8:
Age related cataract. Arnold Publishers, 2003
12. Muralikrishnan R, Venkatesh R, Prajna NV, Frick KD. Economic cost of cataract
surgery procedures in an established eye care centre in Southern India. Ophthalmic
Epidemiol. 2004 Dec;11(5):369–80.
13. Bhargava R, Kumar P, Prakash A, Chaudhary KP. Estimation of mean ND: Yag laser
capsulotomy energy levels for membranous and fibrous posterior capsular opacification.
Nepal J Ophthalmol Biannu Peer-Rev Acad J Nepal Ophthalmic Soc NEPJOPH. 2012
Jun;4(1):108–
14. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J
Ophthalmol. 2012 May;96(5):614–8.
15. Aravind S, Haripriya A, Sumara Taranum BS. Cataract surgery and intraocular lens
manufacturing in India. Curr Opin Ophthalmol. 2008 Jan;19(1):60–5.
16. Steinberg EP, Tielsch JM, Schein OD, Javitt JC, Sharkey P, Cassard SD, et al. The
VF-14. An index of functional impairment in patients with cataract. Arch. Ophthalmol.
1994 May;112(5):630–8.
88
17. Duke Elder S. Cataract. In : System of ophthalmology London, UK: Henry
Kimpton publishers 1976 vol XI p. 36-289.
18 .Varghese. History of the Development of cataract surgery. J of Aravind eye care
system 2001 Oct-Dec; 1(4):37-38.
19. Gimbel HV, Neuhann T. Development, advantages and methods of the continuous
curvilinear capsulorrhexis. J Cataract Refract Surg 1991 ; 17: 110-111.
20. Donaldson KE, Braga-Mele R, Cabot F, et al. Femtosecond laser-assisted cataract
surgery. J Cataract Refract Surg 2013;39:1753-63. [Crossref] [PubMed]
21. Sutton G, Bali SJ, Hodge C. Femtosecond cataract surgery: Transitioning to laser
cataract. Curr Opin Ophthalmol 2013;24:3-8. [Crossref] [PubMed]
22. Cowan LA, Kloek C. Introducing a New Surgical Technology- Controversies in
Femtosecond Laser-assisted Cataract Surgery and Impact on Resident Surgical Training.
Int Ophthalmol Clin 2015;55:23-35. [Crossref] [PubMed]
23. Ali MH, Javaid M, Jamal S, et al. Femtosecond laser assisted cataract surgery,
beginning of a new era in cataract surgery. Oman J Ophthalmol 2015;8:141-6. [Crossref]
[PubMed]
89
24. Khurana AK, Khurana I. Cornea limbus and sclera. In : Anatomy and Physiology of
Eye. New Delhi : CBS publishers and Distributors 2017 .p.31-56
25. American Academy of Ophthalmology. Topographic features of the globe, cornea and
sclera. Sanfrancisco, USA : American Academy of Ophthalmology ;2003.
26. Bron AJ, Tripathi RC, Tripathi BJ. The eye ball and its dimensions. In : Wolff’s
Anatomy of the Eye and Orbit, 8th edition. London: Chapman and Hall Medical, 1997
.p.211-232.
27. Amesbury EC, Miller KM. Correction of astigmatism at the time of cataract surgery.
Curr Opin Ophthalmol. 2009 Jan;20(1):19–24.
28. Naeser K. Assessment and statistics of surgically induced astigmatism. Acta
Ophthalmol. 2008 May;86(3):349.
29 Holladay JT, Moran JR, Kezirian GM. Analysis of aggregate surgically induced
refractive change, prediction error, and intraocular astigmatism. J Cataract Refract Surg.
2001 Jan;27(1):61–79.
30. Sarver EJ, Van Heugten TY, Padrick TD, Hall MT. Astigmatic refraction using peaks
of the interferogram Fourier transform for a Talbot Moiré interferometer. J Refract Surg.
2007 Nov;23(9):972–7.
90
31. Naeser K, Hjortdal J. Polar value analysis of refractive data. J Cataract Refract Surg.
2001 Jan;27(1):86–94.
32. Masket S. Comparison of the effect of topical corticosteroids and nonsteroidals on
postoperative corneal astigmatism. J Cataract Refract Surg. 1990 Nov;16(6):715–8.
33 .Moon SC, Mohamed T, Fine IH. Comparison of surgically induced
astigmatisms after clear corneal incisions of different sizes. Korean J Ophthalmol. 2007
Mar;21(1):1–5.
34. Wei Y-H, Chen W-L, Su P-Y, Shen EP, Hu F-R. The influence of corneal wound size
on surgically induced corneal astigmatism after phacoemulsification. J. Formos. Med.
Assoc. 2012 May;111(5):284–9.
35. Altan-Yaycioglu R, Akova YA, Akca S, Gur S, Oktem C. Effect on astigmatism of the
location of clear corneal incision in phacoemulsification of cataract. J Refract Surg. 2007
May;23(5):515–8.
36. Altan-Yaycioglu R, Pelit A, Evyapan O, Akova YA. Astigmatism induced by oblique
clear corneal incision: right vs. left eyes. Can. J. Ophthalmol. 2007 Aug;42(4):557–61.
37 .Storr-Paulsen A, Madsen H, Perriard A. Possible factors modifying the surgically
induced astigmatism in cataract surgery. Acta Ophthalmol Scand. 1999 Oct;77(5):548–51.
38. Drews RC. Astigmatism after cataract surgery: nylon versus Mersilene. Ophthalmic
Surg. 1989 Oct;20(10):695–6.
91
39. Bigar F. [Astigmatism following cataract surgery: comparison following wound closure
with nylon suture and Mersilene]. Klin Monbl Augenheilkd. 1990 May;196(5):314–5.
40. Bergmann MT,Koch DD, Zeiter JH. The effect of scleral cautery on corneal
astigmatism in cadaver eyes. Ophthalmic Surg. 1988 Apr;19(4):259–62.
41 Gross RH, Miller KM. Corneal astigmatism after phacoemulsification and lens
implantation through unsutured scleral and corneal tunnel incisions. Am. J. Ophthalmol.
1996 Jan;121(1):57–64.
42 Hill W. Expected effects of surgically induced astigmatism on AcrySof toric
intraocular lens results. J Cataract Refract Surg. 2008 Mar;34(3):364–7.
43 Gokhale NS, Sawhney S. Reduction in astigmatism in manual small incision cataract
surgery through change of incision site. Indian J Ophthalmol. 2005 Sep;53(3):201–3.
44 Ruchi Goel KPSM. Manual of Small Incision Cataract Surgery. 2003
45. Cockerham C, Glen, Michael E, Hettinger, Azard DT. Astigmatism and cataract
surgery. In : Alber DM, Jakobiec FA, editors. Principles and practice of ophthalmology
2nd edition, Philadelphia : WB Saunders Company. 2000. p.1538-1548.
46. Paul Erickson OD. Effect of intraocular lens position errors on post operative
refractive error. J Cataract Refract Surg 1990;16:305-310.
92
47. Tsai PS, Dowidar A, Naseri A, McLeod SD. Predicting time to refractive stability after
discontinuation of rigid contact lens wear before refractive surgery. J Cataract Refract
Surg 2004;30: 2290– 2294.
48. Eleftheriadis H. IOLMaster biometry: refractive results of 100 consecutive cases. Br J
Ophthalmol 2003; 87: 960– 963.
49. Borasio E, Stevens J, Smith GT. Estimation of true corneal power after keratorefractive
surgery in eyes requiring cataract surgery: BESSt formula. J Cataract Refract
Surg 2006; 32: 2004– 2014.
50. Adenwala A, Garg A. Recent techniques in nucleus delivery in SICS. In : Garg A, Fry
LL, Tabin G, Gutierrez-Carmona FJ, Pandey SK, editors. Clinical practice in small
incision cataract surgery (Phaco Manual). 1st edn. New Delhi, India : Jaypee brothers
Medical Publishers, 2004 .p.597-611.
51. Kansas P. Phacofracture. In : Rozakis GW, Anis AY, Bryant WR, Kansas P, Keener
GT, editors. Cataract surgery Alternative small incision technique : New Delhi : Jaypee
Brothers Medical Publishers, 1995. p.45-70.
52. Hepsen IF, Cekic O, Bayramlar H, Totan Y : Small Incision Extra Capsular Cataract
Surgery with manual Phacotrisection. J Cataract Refract Surg. 2000;26(7);1048-51.
53. Luther L, Fry. The Phacosandwich Technique. In : Cataract surgery Alternative small
incision technique : New Delhi : Jaypee Brothers Medical Publishers, 1995. p.71-110.
93
54. Bayramlar H, Cekic O, Totan Y. Manual Tunnel Incision Extra Capsular Cataract
Extraction using the Sandwich Technique. J Cataract Refract Surg.1999;25(3):312-15
55. Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Asaria et. The
Cataract National Dataset electronic multicentre audit of 55,567 operations: risk
stratification for posterior capsule rupture and vitreous loss. Eye (Lond) 2009; 23: 31– 37.
56. Osher RH, Yu BC, Koch DD. Posterior polar cataracts: a predisposition to
intraoperative posterior capsular rupture. J Cataract Refract Surg 1990; 16: 157– 162.
57. Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, Canning C al
et. The Cataract National Dataset electronic multi‐centre audit of 55,567 operations:
updating benchmark standards of care in the United Kingdom and internationally. Eye
(Lond) 2009; 23: 38– 49.
58. Scott IU, Flynn HW Jr, Smiddy WE, Murray TG, Moore JK, Lemus DR, Feuer
WJ. Clinical features and outcomes of pars plana vitrectomy in patients with retained lens
fragments. Ophthalmology2003; 110: 1567– 157
59. Stefaniotou M, Aspiotis M, Pappa C, Eftaxias V, Psilas K. Timing of dislocated
nuclear fragment management after cataract surgery. J Cataract Refract
Surg 2003; 29: 1985– 1988.
60. Burk SE, Da Mata AP, Snyder ME, Schneider S, Osher RH, Cionni RJ. Visualizing
vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29: 645– 651.
94
61. Gimbel HV, Sun R, Ferensowicz M, Anderson Penno E, Kamal A. Intraoperative
management of posterior capsule tears in phacoemulsification and intraocular lens
implantation. Ophthalmology2001; 108: 2186 2189; discussion 2190–2182.
62.Chang DF, Masket S, Miller KM, Braga‐Mele R, Little BC, Mamalis N, Oetting TA al
et.Complications of sulcus placement of single‐piece acrylic intraocular lenses:
recommendations for backup IOL implantation following posterior capsule rupture. J
Cataract Refract Surg 2009; 35:1445– 1458.
63 Ling R, Cole M, James C, Kamalarajah S, Foot B, Shaw S. Suprachoroidal
haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features,
management, and outcomes. Br J Ophthalmol 2004; 88: 478– 480.
64. Ling R, Kamalarajah S, Cole M, James C, Shaw S. Suprachoroidal haemorrhage
complicating cataract surgery in the UK: a case control study of risk factors. Br J
Ophthalmol 2004; 88: 474– 477.
65. Santoro S, Sannace C, Cascella MC, Lavermicocca N. Subluxated lens:
phacoemulsification with iris hooks. J Cataract Refract Surg 2003; 29: 2269– 2273.
66. Menapace R, Findl O, Georgopoulos M, Rainer G, Vass C, Schmetterer K. The
capsular tension ring: designs, applications, and techniques. J Cataract Refract
Surg 2000; 26: 898– 912.
95
67. Storr‐Paulsen A, Norregaard JC, Ahmed S, Storr‐Paulsen T, Pedersen TH. Endothelial
cell damage after cataract surgery: divide‐and‐conquer versus phaco‐chop technique. J
Cataract Refract Surg 2008; 34: 996– 1000.
68. Walkow T, Anders N, Klebe S. Endothelial cell loss after phacoemulsification:
relation to preoperative and intraoperative parameters. J Cataract Refract
Surg 2000; 26: 727– 732.
69. Arshinoff SA. Dispersive‐cohesive viscoelastic soft shell technique. J Cataract Refract
Surg 1999;25: 167– 173.
70. Tarnawska D, Wylegala E. Effectiveness of the soft‐shell technique in patients with
Fuchs' endothelial dystrophy. J Cataract Refract Surg 2007; 33: 1907– 1912.
71. Rainer G, Menapace R, Findl O, Kiss B, Petternel V, Georgopoulos M, Schneider
B. Intraocular pressure rise after small incision cataract surgery: a randomised
intraindividual comparison of two dispersive viscoelastic agents. Br J
Ophthalmol 2001; 85: 139– 142.
72. Borazan M, Karalezli A, Akman A, Akova YA. Effect of antiglaucoma agents on
postoperative intraocular pressure after cataract surgery with Viscoat. J Cataract Refract
Surg 2007; 33: 1941– 1945.
73. Meacock WR, Spalton DJ, Boyce J, Marshall J. The effect of posterior capsule
opacification on visual function. Invest Ophthalmol Vis Sci 2003; 44: 4665– 4669.
96
74. Wormstone IM, Wang L, Liu CS. Posterior capsule opacification. Exp Eye
Res 2009; 88: 257– 269.
75. Findl O, Buehl W, Bauer P, Sycha T. Interventions for preventing posterior capsule
opacification. Cochrane Database Syst Rev 2007: CD003738.
76 Hollick EJ, Spalton DJ, Ursell PG, Pande MV. Lens epithelial cell regression on the
posterior capsule with different intraocular lens materials. Br J
Ophthalmol 1998; 82: 1182– 1188.
77. Smith SR, Daynes T, Hinckley M, Wallin TR, Olson RJ. The effect of lens edge design
versus anterior capsule overlap on posterior capsule opacification. Am J
Ophthalmol 2004; 138: 521– 526.
78. Thompson AM, Sachdev N, Wong T, Riley AF, Grupcheva CN, McGhee CN. The
Auckland Cataract Study: 2 year postoperative assessment of aspects of clinical, visual,
corneal topographic and satisfaction outcomes. Br J Ophthalmol 2004; 88: 1042– 1048.
79. Aslam TM, Devlin H, Dhillon B. Use of Nd:YAG laser capsulotomy. Surv
Ophthalmol 2003; 48:594– 612.
80. Jahn CE, Richter J, Jahn AH, Kremer G, Kron M. Pseudophakic retinal detachment
after uneventful phacoemulsification and subsequent neodymium: YAG capsulotomy for
capsule opacification. J Cataract Refract Surg 2003; 29: 925– 929.
97
81. Wright PL, Wilkinson CP, Balyeat HD, Popham J, Reinke M. Angiographic cystoid
macular edema after posterior chamber lens implantation. Arch
Ophthalmol 1988; 106: 740– 744.
82. Henderson BA, Kim JY, Ament CS, Ferrufino‐Ponce ZK, Grabowska A, Cremers
SL. Clinical pseudophakic cystoid macular edema. Risk factors for development and
duration after treatment.J Cataract Refract Surg 2007; 33: 1550– 1558
83. Clark WL, Kaiser PK, Flynn HW Jr, Belfort A, Miller D, Meisler DM. Treatment
strategies. and visual acuity outcomes in chronic postoperative Propionibacterium acnes
endophthalmitis.Ophthalmology 1999; 106: 1665– 1670.
84. Deramo VA, Ting TD. Treatment of Propionibacterium acnes endophthalmitis. Curr
Opin Ophthalmol 2001; 12: 225– 229.
85. Ramalakshmi V, Rani MRH, Rajalakshmi A, Anandan H. Comparison of Merits and
Demerits of Manual Small Incision Cataract Surgery with Phacoemulsification. Int J Sci
Stud 2017;4(12):161-163.
CONSENT FORM
STUDY: A COMPARATIVE STUDY OF VISUAL OUTCOME
AND COMPLICATIONS IN PHACOEMULSIFICATION AND MANUAL SMALL
INCISION CATARACT SURGERY
I Mr / Mrs / Ms -------------------------have been explained in a language best known to
me about my participation in the following study “A COMPARATIVE STUDY OF
VISUAL OUTCOME AND COMPLICATIONS IN PHACOEMULSIFICATION AND
MANUAL SMALL INCISION CATARACT SURGERY” in patients at Raja Rajeswari
medical college and hospital Bengaluru. I have also been explained the procedure and
the related risks and possible complications that may be involved. I shall not hold
doctors or the staff responsible for any untoward consequences.
I have read the information above and have understood wholly and give my
voluntary consent for the same.
INTERVIEWERS NAME PATIENTS NAME
SIGNATURE SIGNATURE OR
THUMB IMPRESSION
DATE
PLACE
98
99
ETHICAL COMMITTE CLEARANCE LETTER
100
PROFORMA
1. NAME OF THE PATIENT:- :
2. AGE:-
3. SEX:-
4. OCCUPATION
5. ADDRESS:-
6. CONTACT NUMBER:-
7. OP NUMBER:-
8. IP NUMBER:-
9. DATE OF ADMISSION
10. DATE OF SURGERY
11. DATE OF DISCHARGE
PARAMETERS:-
1. PRESENTING COMPLAINTS - H/O DIMINISION OF VISION,ITS
DURATION,NATURE
2. PAST HISTORY - ANY KNOWN CASE OF
DIABETES/HYPERTENSION/ASTHMA/TB/CARDIAC AILMENT
3. FAMILY HISTORY
4. PERSONAL HISTORY
5. GENERAL PHYSICAL EXAMINATION
6. LOCAL EXAMINATION
101
RE LE
1. Position of the Head
2. Eye lids
3. Lacrimal apparatus
4. Conjunctiva
5. Cornea
6. Sclera
7. Anterior chamber
8. Iris
9. Pupil :
10. Lens Type of cataract
11.VA Unaided
12. Best corrected VA
13. Retinoscopy :
14. Near vision
15. IOP
16. Lacrimal sac syringing
17. Macular function tests
18. Fundus :
Media :
Disc :
Vessels
Macula
BGR
7. SLIT LAMP EXAMINATION: Type of cataract: Nuclear Grade :
8. KERATOMETRY AXIS K1:
102
K2:
9. BIOMETRY
AXL:
PCIOL:
ACIOL:
10. B SCAN
11. INVESTIGATIONS – Random blood sugar
Serology
FOLLOW UP OF PATIENTS-
FOLLOW UP
PERIOD
VISUAL ACUITY SLIT LAMP EXAMINATION
FINDINGS
FUNDOSCOPY
1ST WEEK
2ND WEEK
6TH WEEK
6TH WEEK
UNCORRECTED
UNCORRECTED
UNCORRECTED
BEST
CORRECTED
INTRAOPERATIVE COMPLICATIONS –
POST OPERATIVE COMPLICATIONS -
108
SERIAL NO
NAME AGE SEX I.P. NO EYE R/L PREOPERATIVE VISION
TYPES OF SURGERY
INTRA OPERATIVE COMPLICATIONS
POST OPERATIVE COMPLICATIONS
POST OPERATIVE VISION
ASTIGMATISM
1ST WEEK 2ND WEEK
6TH WEEK
BCVA AT END OF 6 WEEKS
RERACTION
1 CHENNAMMA 72 F 101 LE CF@ 2 mts MSICS NIL NIL 6/6 6/9 6/9 6/6 -0.50DS -0.50DC 90˚ ATR
2 RAME GOWDA 56 M 245 LE HMCF MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.75DC 90˚ ATR
3 RAMESH REDDY 67 M 356 RE HMCF MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.50DS -1.5DC 90˚ ATR
4 KRISHNA MOORTHY 55 M 566 LE HMCF MSICS NIL NIL 6/9 6/9 6/9 6/6 -0.50DS -
5 JAYAMMA 65 F 853 RE CF@ 2 mts MSICS NIL STRIATE KERATOPATHY 6/60 6/24 6/12 6/9 -0.50DS -0.5DC 90˚ ATR
6 RAJESWARI 67 F 1098 RE 6/60 MSICS NIL NIL 6/24 6/9 6/12 6/6 -0.5DS -0.50 DC 90˚ ATR
7 RAVINDRAN 64 M 1871 LE CF @ 3 mts MSICS NIL NIL 6/9 6/9 6/12 6/6 -0.75 DC 90˚ ATR
8 SHIVAMMA 53 F 3445 RE 6/36 MSICS NIL ANTERIOR UVEITIS 6/24 6/18 6/18 6/12 -0.75 DS -0.50DC 180˚ WTR
9 JAYALAKSHMAMMA 78 F 12356 RE PL PR + ve MSICS NIL NIL 6/12 6/12 6/12 6/6 0.50 DS -0.1DC 90˚ ATR
10 NAGALAKSHMI 56 F 13689 RE HMCF MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.50DS -0.50DC 90˚ ATR
11 YASMIN BANU 53 F 20987 LE 6/18 MSICS NIL NIL 6/9 6/6 6/6 6/6 NO CORRECTION -
12 RAJASHEKAR 58 M 24323 RE 6/60 MSICS NIL NIL 6/18 6/12 6/9 6/6 -0.75DC 180˚ WTR
13 GULAB JAN 51 F 30349 LE 6/18 MSICS NIL NIL 6/9 6/9 6/12 6/9 -0.50DC 90˚ ATR
14 THULASI 53 F 30457 LE PL PR + ve MSICS IRIDODIALYSIS NIL 6/60 6/24 6/24 6/12 -0.50DS -1.25 DC 90˚ ATR
15 JADIAPPA 70 M 30362 LE CF @ 1 mts MSICS NIL NIL 6/12 6/12 6/12 6/6 -1DS -
16 RAFIQ AHMED 60 M 26842 RE 6/12 MSICS NIL NIL 6/6 6/6 6/9 6/6 -0.75 DC 90˚ ATR
17 APPAJAIAH 50 M 28686 LE 6/60 MSICS NIL NIL 6/9 6/9 6/9 6/6 -0.50 DC 180˚ WTR
18 PRABHAMANI 51 F 29411 LE HM CF MSICS NIL NIL 6/6 6/9 6/9 6/9 NO CORRECTION -
19 PUTTAMMA 81 F 24601 RE PL PR + ve MSICS PCR WITHOUT VITREOUS LOSS
NIL 6/24 6/18 6/18 6/9 -0.75DS -1DC 90˚ ATR
20 VIJAYALAKSHMI 60 F 28788 RE 6/24 MSICS NIL NIL 6/6 6/9 6/9 6/6 -0.50 DC 180˚ WTR
21 SAVADAMMAL 76 F 29638 RE CF @ 3 mts MSICS NIL NIL 6/9 6/12 6/12 6/9 -0.50 DS-0.50 DC 90˚ ATR
22 HANUMAKKA 85 F 26787 RE 6/18 MSICS NIL NIL 6/9 6/9 6/9 6/6 -1DC 180 WTR
23 MALLIGA 50 F 28765 RE HMCF MSICS NIL NIL 6/12 6/9 6/12 6/9 -0.50 -0.75 DC 90˚ ATR
24 ARUVAMMA 59 F 27232 LE 6/24 MSICS NIL NIL 6/18 6/18 6/12 6/6 -0.50DS -1 DC 180 WTR
25 PARVEEN 71 F 23052 RE 6/18 MSICS NIL NIL 6/12 6/9 6/9 6/6 -0.50 DS-0.50 DC 90˚ ATR
26 SIDDAGANGAMMA 54 F 28144 RE 6/60 MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.75 DS ATR
27 PUTTASWAMIAIAH 58 M 28643 RE CF @ 2 mts MSICS NIL HYPHEMA HMCF 6/24 6/24 6/18 0.50DS -0.75 DC 180˚ WTR
28 APPAJAIAH 63 M 29656 LE CF @ 3 mts MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.50DS -0.50 DC 90˚ ATR
29 KAILASAPPA 72 M 28216 LE 6/24 MSICS NIL NIL 6/9 6/9 6/12 6/6 -0.75DC 90˚ ATR
30 LEKHO PRASAD 55 M 28787 RE CF @ 2 mts MSICS NIL NIL 6/18 6/12 6/12 6/9 -0.25DS -0.5DC 90˚ ATR
31 MALLIGA 59 F 26787 LE 6/60 MSICS NIL NIL 6/12 6/12 6/9 6/6 -0.25DS -0.25DC 180˚ WTR
32 RANGAMMA 53 F 28820 RE PL PR + ve MSICS NIL ANTERIOR UVEITIS 6/24 6/18 6/18 6/12 -0.50 DS-0.50 DC 90˚ ATR
33 KAMALAMMA 64 F 28565 LE HMCF MSICS NIL NIL 6/9 6/9 6/12 6/6 -0.75DC 90˚ ATR
34 HANUMAKKA 52 F 436 RE 6/18 MSICS NIL NIL 6/12 6/12 6/12 6/6 -0.5DS -0.1.5DC 180 WTR
35 HARIPRIYA 50 F 1347 LE 6/24 MSICS NIL NIL 6/18 6/18 6/18 6/9 -1DS -2DC 90˚ ATR
36 INDRA 51 F 34521 RE 6/60 MSICS NIL IRIS PROLAPSE 6/24 6/18 6/12 6/9 -0.75DS -
37 LAKSHMAMMA 76 F 765 RE CF @ 3 mts MSICS NIL NIL 6/9 6/12 6/12 6/6 -1DS -0.50DC 90˚ ATR
38 GOWRAMMA 65 F 9832 RE 6/24 MSICS NIL NIL 6/12 6/12 6/9 6/6 -0.25DS -0.25DC 90˚ ATR
109
39 HONNAMMA 70 F 10987 RE CF @ 2 mts MSICS NIL NIL 6/18 6/12 6/12 6/9 -0.50DS -0.50DC 90˚ ATR
40 JAYAMMA 59 F 2356 RE HMCF MSICS NIL NIL 6/24 6/12 6/18 6/12 -0.75DC 90˚ ATR
41 RAMACHANDRA 68 M 11278 LE 6/60 MSICS NIL NIL 6/9 6/9 6/9 6/9 NO CORRECTION -
42 THIMMAIAH 73 M 19845 RE PL PR + ve MSICS PCR WITHOUT VITREOUS LOSS
NIL 6/36 6/24 6/24 6/9 -2DS -2DC 90˚ ATR
43 KAMALAMMA 63 F 26489 LE CF @ 3 mts MSICS NIL NIL 6/18 6/18 6/12 6/9 -1.5DC 90˚ ATR
44 PUTTABASAMMA 68 F 5672 LE 6/24 MSICS NIL NIL 6/18 6/24 6/24 6/6 -2.5DC90˚ ATR
45 KRISHNAPPA 67 M 34897 RE 6/18 MSICS NIL NIL 6/24 6/18 6/12 6/6 -1.25DC 180˚ WTR
46 SHAMEEM 68 M 23970 RE CF @ 2 mts MSICS NIL CORNEAL EDEMA 6/60 6/12 6/12 6/9 -0.50DS -0.5DC 90˚ ATR
47 DEVARAJU 67 M 37894 RE HMCF MSICS NIL NIL 6/12 6/12 6/12 6/6 -0.25DS -0.25DC 90˚ ATR
48 JEYAMMA 54 F 3489 LE CF @ 2 mts MSICS NIL NIL 6/24 6/12 6/12 6/9 -0.75 DS -
49 RAJALAKSHMI 55 F 2578 LE 6/60 MSICS NIL NIL 6/12 6/9 6/9 6/6 -05DS -0.75DC 90˚ ATR
50 KHADRAPPA 62 M 8991 RE 6/36 MSICS NIL NIL 6/6 6/9 6/12 6/6 0.75DS -0.75DC 90˚ ATR
51 REVANNA 85 M 30987 LE PL PR + ve MSICS NIL NIL 6/24 6/24 6/24 6/9 +0.50DS -2.5DC 90˚ ATR
52 BHARATHI 50 F 34645 LE CF @ 1/2 mts MSICS NIL NIL 6/18 6/18 6/18 6/9 -0.75 -2.25DC 90˚ ATR
53 SAVITHA 53 F 4569 RE 6/18 MSICS NIL NIL 6/36 6/18 6/18 6/9 -0.5DS -0.5DC 90˚ ATR
54 JAYAMMA 65 F 12784 RE PL PR + ve MSICS NIL STRIATE KERATOPATHY CF @ 2 mts 6/24 6/12 6/9 -0.75DS -0.75DC 90˚ ATR
55 CHANNAIAH 66 M 22890 RE 6/60 MSICS NIL NIL 6/18 6/12 6/12 6/6 -0.75DS -1.25 DC 180˚ WTR
56 RAVICHANDRAN 57 M 45890 LE 6/18 MSICS NIL NIL 6/12 6/9 6/9 6/6 -0.5DS -0.5DC 90˚ ATR
57 YASMEEN 56 F 44321 RE CF @ 1/2 mts MSICS NIL NIL 6/12 6/18 6/18 6/12 -1DC 90˚ ATR
58 JAHANERA 65 F 5432 LE 6/36 MSICS NIL NIL 6/24 6/24 6/18 6/9 -0.75DS -1DC 90˚ ATR
59 SHIVLINGAIAH 77 M 4890 RE 6/18 MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.50DS -0.75DC 90 ATR
60 PEDAKKA 74 F 54378 LE 6/24 MSICS NIL NIL 6/18 6/18- 6/12 6/6 -1DS -1DC 90˚ ATR
61 NARAYANNAPA 59 M 60952 RE CF @ 3 mts MSICS NIL NIL 6/12 6/12 6/9 6/6 -0.25DS -0.25DC 90˚ ATR
62 SHARADHA 56 F 56679 LE PL PR + ve MSICS NIL NIL 6/60 6/36 6/24 6/12 -0.50DS -2DC 90˚ ATR
63 PALANI 67 M 4552 RE HMCF MSICS NIL CORNEAL EDEEMA CF @ 3 mts 6/24 6/18 6/12 -0.50DS -0.5DC 90˚ ATR
64 SUNANDHAMMA 69 F 78910 LE 6/60 MSICS NIL NIL 6/24 6/18 6/12 6/9 -0.25DS -1DC 90˚ ATR
65 DEVIBAI 70 F 34732 RE HMCF MSICS NIL NIL 6/24 6/12 6/12 6/6 -0.75DS -1.DC 90˚ ATR
66 NARASAMMA 74 F 45521 RE CF @ 2 mts MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.50DS -0.75 DC 90˚ ATR
67 ANWAR 50 M 42236 RE 6/18 MSICS NIL NIL 6/12 6/18 6/18 6/12 -0.50DS -0.50DC 90˚ ATR
68 NAVANEEDHAMMA 53 F 40985 RE 6/24 MSICS NIL NIL 6/18 6/24 6/24 6/9 -1DS -1.50DC 90˚ ATR
69 BORAIAH 61 M 46901 LE CF@ 2 mts MSICS NIL NIL 6/9 6/6 6/6 6/6 NO CORRECTION -
70 VENKATESH 58 M 28891 LE CF @ 1mt MSICS NIL NIL 6/12 6/12 6/9- 6/6 -0.25DS -0.5DC 90˚ ATR
71 THULASSAMMA 60 F 56689 RE PL PR + ve MSICS NIL NIL 6/24 6/24 6/9 6/9 -0.75DS -0.75DC 90˚ ATR
72 RANGAMMA 73 F 79987 RE 6/36 MSICS NIL NIL 6/24 6/18 6/12 6/6 -0.5DS -1DC 90˚ ATR
73 RANGANATH 69 M 95390 LE 6/60 MSICS NIL NIL 6/36 6/12 6/9- 6/6 -0.25DS -0.50DC 90˚ ATR
74 MOHAMMAD GOUZ 59 M 23356 RE CF @ 3 mts MSICS NIL NIL 6/60 6/24 6/18 6/9 -0.7DDS -0.50DC 90˚ ATR
75 JAYAMMA 63 F 1478 RE PL PR + ve MSICS NIL CORNEAL EDEMA CF @ 2 mts 6/18 6/12 6/9 -0.50DS -0.50DC 90˚ ATR
76 NASIKHAN 59 M 36876 LE 6/18 MSICS NIL NIL 6/9 6/12 6/12 6/9 0.75DC 80˚ ATR
77 SHIVAMMA 61 F 35907 LE 6/60 MSICS NIL NIL 6/36 6/18 6/18 6/6 -0.75DS -2DC 90˚ ATR
78 RUDRAPPA 68 M 67990 LE CF @ 3 mts MSICS NIL NIL 6/24 6/24 6/12 6/6 -0.75DS -0.75DC 90˚ ATR
79 BAJJAIAH 74 M 66321 RE 6/18 MSICS NIL NIL 6/9 6/9 6/9 6/6 -0.50-0.75DC 90˚ ATR
80 NARASAMMA 77 F 75432 LE 6/24 MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.25DS -0.25DC 90˚ ATR
81 SHIVAMMA 69 F 89945 RE 6/24 MSICS NIL NIL 6/12 6/9 6/9 6/6 -0.75DC 90˚ ATR
82 RUDRAPPA 54 M 1290 RE CF @ 2 mts MSICS NIL NIL 6/18 6/18 6/9 6/6 -0.5DS -0.5DC 90˚ ATR
110
83 BASAVAMMA 64 F 32789 RE PL PR + ve MSICS PCR WITH VITREOUS LOSS
NIL 6/60 6/18 6/24 6/18 -0.5DS -0.75DC 90˚ ATR
84 MUNIRAJU 57 M 56687 RE CF @ 1/2 mts MSICS NIL NIL 6/18 6/12 6/12 6/9 -0.25DS -0.5DC 90˚ ATR
85 LAXMI 53 F 46743 LE 6/60 MSICS NIL NIL 6/24 6/9 6/9 6/6 -0.75DS -0.75DC 90˚ ATR
86 CHIKAMMA 69 F 38965 RE 6/18 MSICS NIL NIL 6/18 6/9 6/9 6/6 -0.75DC 90˚ ATR
87 MARGARET 68 F 40987 RE CF @ 1/2 mts MSICS NIL NIL 6/36 6/24 6/12 6/9 -0.50-0.75DC 90˚ ATR
88 THAIMUDAMMA 72 F 37990 RE 6/24 MSICS NIL NIL 6/24 6/18 6/9 6/6 -1DC 90˚ ATR
89 GOWRI BAI 61 F 43217 LE CF @ 2 mts MSICS NIL NIL 6/9 6/12 6/12 6/6 -0.50DS -0.5DC 180˚ WTR
90 LAKKE GOWDA 58 M 57654 RE 6/60 MSICS NIL NIL 6/6 6/9 6/18 6/9 -1.25DS -1DC 90˚ ATR
91 MUTHAPPA 53 M 42189 LE 6/24- MSICS NIL NIL 6/18 6/12 6/9 6/6 -0.5DS -
92 VEKATAGIRIAPPA 59 M 69943 LE CF @ 3 mts MSICS NIL CME 6/60 6/12 6/9 6/6 -0.75 -0.5DC 90˚ ATR
93 SAKAMMA 56 F 32987 RE PL PR + ve MSICS NIL NIL 6/36 6/12 6/12 6/9 -0.75DC 90˚ ATR
94 MANJULA 62 F 30993 RE 6/24- MSICS NIL NIL 6/24 6/24 6/24 6/9 -2 DS -2DC 90˚ ATR
95 GOWRAMMA 75 F 21733 LE 6/18- MSICS NIL NIL 6/18 6/9 6/12 6/9 -0.25 DS -0.75DC 90˚ ATR
96 RAJA NAYAK 54 M 20932 RE 6/60- MSICS NIL NIL 6/24 6/18 6/18 6/6 -0.75 DS -1.75 DC 90˚ ATR
97 MOULA 63 M 70332 LE CF @ 3 mts MSICS NIL NIL 6/12 6/12 6/12 6/6 -0.75DS -0.75 DC 90˚ ATR
98 CHANDRAMMA 69 F 87450 RE 6/60 MSICS NIL NIL 6/60 6/24 6/18 6/9 -1.25 DS -1DC 90˚ ATR
99 MUNIYALLAMMA 58 F 11907 RE HMCF MSICS NIL NIL 6/12 6/12 6/12 6/9 -0.75 DC 90˚ ATR
100 RAJU 57 M 26905 LE HMCF MSICS NIL CME 6/36 6/18 6/18 6/9 -0.5DS -0.5DC 90˚ ATR
101 NANJAMMA 80 F 98765 LE 6/60 PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.25DS -0.25DC 90˚ ATR
102 SULOCHANA 56 F 88564 RE CF @ 3 mts PHACO NIL NIL 6/9 6/9 6/9 - -
103 JETHENDRA KUMAR 59 M 45000 RE HMCF PHACO NIL NIL 6/12 6/9 6/9 - -
104 MAHADAIAH 67 M 23567 LE 6/60 PHACO NIL NIL 6/9 6/9 6/6 - -
105 MANJUNATH 66 M 34521 RE HMCF PHACO PHACO BURN NIL 6/60 6/18 6/9 6/6 -0.50DS -0.5DC 90˚ ATR
106 KAMALAMMA 78 F 76544 RE CF @1 mt PHACO NIL NIL 6/18 6/12 6/9 6/6 -0.5DC 90˚ ATR
107 KAVITHA 50 F 56321 RE CF@ 3 mts PHACO NIL NIL 6/9 6/9 6/9 - -
108 MANCHA 52 M 33367 LE HMCF PHACO NIL NIL 6/12 6/12 6/12 6/6 -1CS -0.5 DC 90˚ ATR
109 SULOCHANA 56 F 12378 LE 6/24 PHACO NIL NIL 6/6 6/6 6/6 - -
110 PUTTASIDDEGOWDA 68 M 56321 RE 6/36 PHACO NIL NIL 6/9 6/9 6/9 - -
111 JAYALAKSHMAMMA 66 F 69990 LE PL PR + ve PHACO PCR WITH VITREOUS LOSS
NIL 6/60 6/18 6/12 6/9 -0.75DS -0.25DC 90˚ ATR
112 MURTHUZA KHAN 58 F 45523 RE 6/18 PHACO NIL NIL 6/9 6/9 6/6 - -
113 SHAMANNA 53 M 32109 LE 6/24 PHACO NIL NIL 6/9 6/6 6/6 - -
114 SHANKAR 59 M 30090 RE CF @ 2 mts PHACO NIL NIL 6/6 6/6 6/6 - -
115 NANJAMMA 65 F 78854 LE PL PR + ve PHACO NIL ANTERIOR UVEITIS 6/60 6/24 6/9 6/6 -0.5DC 90˚ ATR
116 PAPAMMA 76 F 89432 LE CF @1 mt PHACO NIL NIL 6/24 6/18 6/18 6/6 -1.75DS -0.5DC 90˚ ATR
117 ANNAPPA 79 M 99542 LE 6/36 PHACO NIL NIL 6/9 6/9 6/9 - - -
118 KUMARANNA 73 M 5667 RE 6/18 PHACO NIL NIL 6/6 6/6 6/6 - - -
119 SHAKUNTHALA 59 F 4321 RE HMCF PHACO NIL NIL 6/12 6/9 6/9 6/6 -0.75DC 90˚ ATR
120 SHIVAMMA 60 F 13456 LE HMCF PHACO NIL NIL 6/12 6/12 6/12 - - -
121 MUTHAPPA 53 M 19875 LE CF@2 mts PHACO NIL NIL 6/9 6/9 6/9 - -
122 NARENDRA 58 M 27895 RE 6/24 PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.5-0.5D 90 ATR
123 LINGAMMA 65 F 17700 LE PL PR + ve PHACO NIL NIL 6/18 6/12 6/9 - -
124 PUTTATHAYAMMA 69 F 74321 LE 6/60 PHACO NIL CORNEAL EDEMA HMCF CF @ 1 mt
CF @ 1 mt
CF @ 1mt -
111
125 BASAVARAJU 71 M 99411 RE HMCF PHACO NIL NIL 6/12 6/9 6/9 6/6 -0.25DS -0.25DC 90˚ ATR
126 UMESHA 55 M 56321 RE CF @ 3 mts PHACO NIL NIL 6/9 6/9 6/6 - -
127 SARASWATHI 58 F 23499 LE 6/24 PHACO NIL NIL 6/6 6/6 6/6 - -
128 SUSHEELA BAI 52 F 4589 RE 6/36 PHACO NIL NIL 6/12 6/12 6/12 6/9 -0.5DC 90˚ ATR
129 LAKSHMAMMA 69 F 52134 LE PL PR + ve PHACO NIL NIL 6/24 6/18 6/18 6/9 -1.5DS-0.DC 90˚ ATR
130 MUNIKRISHNAPPA 70 M 90542 LE 6/36 PHACO NIL NIL 6/9 6/9 6/9 - -
131 SIDDAMMA 63 F 17432 RE 6/60 PHACO NIL NIL 6/12 6/9 6/9 6/6 -0.5DS-0.5DC 90˚ ATR
132 ASIFULLA 58 M 11900 RE 6/18 PHACO NIL NIL 6/6 6/6 6/6 - -
133 SWAMY 57 M 34700 RE CF@ 1/2 mts PHACO NIL NIL 6/18 6/12 6/12 6/9 -0.25DS-0.25DC 90 ATR
134 VAIRAMUTHU 73 M 32600 LE CF @ 2mts PHACO NIL CORNEAL EDEMA CF @ 2 mts 6/24 6/9 - -
135 SIDDEGOWDA 70 M 81231 LE 6/24 PHACO NIL NIL 6/12 6/9 6/9 - -
136 RASHEEDA BEGUM 53 F 79432 RE PL PR + ve PHACO NIL NIL 6/24 6/18 6/18 6/9 -2DS -0.5DC 90˚ ATR
137 NARASAMMA 63 F 15890 RE 6/60 PHACO NIL NIL 6/6 6/6 6/6 - -
138 ALUMELAMMA 61 F 1843 LE CF@ 2mts PHACO NIL NIL 6/9 6/9 6/9 - -
139 BALARAM 70 M 29560 RE HMCF PHACO NIL NIL 6/12 6/12 6/9 - -
140 MUNEERA BAI 59 F 53289 LE 6/24 PHACO NIL NIL 6/9 6/9 6/9 - -
141 NANJUNDAIAH 54 M 38965 RE 6/18 PHACO NIL NIL 6/9 6/9 6/9 - -
142 LINGAPPA 65 M 18890 LE HMCF PHACO NIL NIL 6/12 6/9 6/9 6/6 -0.25DS -0.25DC 90˚ ATR
143 NANJUNDE GOWDA 69 M 3777 LE 6/24- PHACO NIL PCR 6/18 6/18 6/12 - -
144 MANJAIAH 64 M 21890 LE PL PR + ve PHACO NIL ANTERIOR UVEITIS 6/24 6/9 6/9 - -
145 SYED PASHA 61 M 39950 LE CF @ 3 mts PHACO NIL NIL 6/12 6/9 6/6 - -
146 KARIYAPPA 76 M 53211 RE 6/60 PHACO NIL NIL 6/9 6/9 6/9 - -
147 SHANKARAPPA 55 M 67844 RE CF@ 3 mts PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.5DS -0.5DC 90˚ ATR
148 JAYALAKSHMI 63 F 2389 LE HMCF PHACO NIL NIL 6/9 6/9 6/9 - -
149 RATHNAMMA 79 F 131 RE 6/18 PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.25DS -0.25DC 90˚ ATR
150 DEVIRAMMA 58 F 4521 RE 6/24 PHACO NIL NIL 6/9 6/9 6/9 - -
151 JEETHENDRA PAL 50 M 34908 RE 6/36 PHACO NIL NIL 6/12 6/9 6/9 - -
152 THIPAMMA 58 F 73094 LE 6/60 PHACO PCR WITHOUT VITREOUS LOSS
NIL 6/12 6/9 6/6 - -
153 HANUMANTHI 63 F 44950 RE CF @ 1 mts PHACO NIL STRIATE KERATOPATHY
CF@ 2 mts 6/24 6/12 6/9 -0.25DS -0.25DC 90˚ ATR
154 MEENAKSHI 66 F 48993 RE 6/24 PHACO NIL NIL 6/9 6/9 6/9 - -
155 VIJAYALAKSHMI 59 F 32190 RE 6/18 PHACO NIL NIL 6/12 6/12 6/12 6/6 -1.5DS -0.5 DC 90˚ ATR
156 MD ASLAM 70 M 39632 LE CF @ 2 mts PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.5DS -0.5DC 90˚ ATR
157 MUNIYALLAMMA 60 F 46987 LE PL PR + ve PHACO NIL NIL 6/24 6/24 6/18 6/9 -1.25.DS -0.75DC 90˚ ATR
158 DODAMMA 64 F 42764 RE HMCF PHACO NIL NIL 6/9 6/9 6/9 - -
159 DEVAMMA 67 F 52190 RE CF@ 3 mts PHACO NIL NIL 6/12 6/9 6/9 - -
160 ANANDAMMA 68 F 19345 LE 6/60 PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.25DS -0.25DC 90˚ ATR
161 KRISHNAVENI 52 F 67743 RE 6/24 PHACO NIL NIL 6/6 6/6 6/6 - -
162 KARAMMA 51 F 7443 RE CF @ 2 mts PHACO NIL NIL 6/24 6/18 6/12 6/9 -0.25DS -0.5DC 90˚ ATR
163 MARIGOWDA 67 M 84210 RE HMCF PHACO NIL STRIATE KERATOPATHY
CF @ 2 mts 6/24 6/12 6/9 -0.5DS -0.5DC 90˚ ATR
164 APPAJI 66 M 6442 LE CF @ 2 mts PHACO NIL NIL 6/12 6/9 6/9 6/6 -0.5DS -0.25 DC 90 ATR
165 VARADHARAJU 60 M 568 LE 6/18 PHACO NIL NIL 6/9 6/9 6/6 - -
166 HANUMESH ACHAR 59 M 45218 RE HMCF PHACO NIL NIL 6/12 6/9 6/9 - -
}67 GANGAMMA I 6 4 M 51876 LE PL PR+ ve PHACO NIL NIL 6/18 6/9 I 6/6 I- \ '- -I 168 SHIVAMMA 65 F 50032 RE 6/60 PHACO NIL NIL 6/9 6/9 6/9 I - \- \ I 169 AMEENA 81 58 M 40210 RE CF@ 1 mts PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.25D5 -0 .25DC 90" ATR
r 170 MANJAMMA 60 F 61893 LE CF@3 mts PHACO NIL NIL 6/9 6/9 6/9 6/6 -0.50C90" ATR
171 MUTHAMMA 62 F 6339 RE 6/60 PHACO NIL NIL 6/9 6/9 6/9 .
172 , MARIYAM MA 62 F 90432 RE PL PR+ ve MSICS NIL ANTERIOR UVEITIS CF@ 3 mts 6/18 6/18 6/9 -20S -0 .SDC 90• ATR
l 173 BASAVARAJU 71 M 88909 RE HMCF PHACO NIL NIL 6/12 6/9 6/9 6/6 -0.750S -0.5DC 90" ATR
174 JYOTHI 58 F 456 RE 6/60 PHACO NIL NIL 6/12 6/9 6/9 .
175 AM BUJAMMA 63 F 12900 LE CF@ 2 mts PHACO NIL NIL 6/9 6/9 6/9 .
176 , KRISHNAPPA 68 M 3467 LE 6/36 PHACO NIL NIL 6/9 6/9 6/6 .
l 177 NARASAMMA 68 F 19345 RE CF@ 1 mt PHACO NIL NIL 6/18 6/9 6/9
178 NANJAMMA 62 F 45890 LE 6/24 PHACO NIL NIL 6/9 6/9 6/6
179 I SHIVLI NGAIAH 81 M 32178 LE HMCF PHACO NIL NIL 6/12 6/9 6/9 6/6 0.750 S -0 .SODC 90" ATR
I 180 1 GU LZAR BANU 58 F 23906 LE CF@2 mts PHACO NIL NIL 6/9 6/9 6/6 .
181 NANJAPPA 61 M 44089 LE 6/18 PHACO NIL NIL 6/6 6/6 6/6 .
182 MAHADEVAM MA 64 F 88567 RE PL PR +ve PHACO NIL NIL 6/18 6/12 6/9 6/6 -0.5 OS -0.25 DC 90· ATR
I 183 ATHULAHM ED 57 M 34000 RE CF@3 mts PHACO DM NIL 6/24 6/12 6/12 .
DETACHM ENT
184 KAMALAMMA 60 F 32189 LE 6/60 PHACO NIL NIL 6/12 6/9 6/9
185 M OHAN 55 M 57900 RE CF@ 3 mt s PHACO Nil NIL 6/24 6/12 6/12 6/9 -0 . 750 S -0.SDC 90 • ATR
186 CHIKANNA 66 M 32189 LE 6/36 PHACO NIL NIL 6/12 6/9 6/9 . 187 GOWRAMMA 67 F 90664 RE 6/18 PHACO NIL NIL 6/9 6/9 6/6
188 SU LOCHANA 58 F 20002 LE 6/24 PHACO Nil NIL 6/9 6/6 6/6
I 189 SU SH ELAM MA 56 F 12874 RE HMCF PHACO NIL NIL 6/12 6/9 6/9
190 CHOW DAM MA 63 F 3490 LE 6/18 PHACO NIL NIL 6/9 6/9 6/6 .
191 RAJA RAM 60 M 400 RE 6/36 PHACO NIL NIL 6/9 6/9 6/9
192 M ANJUNATH 68 M 32190 RE CF@ 2 mts PHACO NIL NIL 6/18 6/12 6/12 6/9 -20S -0.SODC 90· ATR
193 AMBUJAMMA 60 F 50043 LE 6/60 PHACO PCR WITHOUT NIL 6/60 6/18 6/9 6/6 -0.SDS -0.SDC 90· ATR VITREOUS LOSS
194 ALU MELU 71 F 73421 RE 6/18 PHACO NIL NIL 6/9 6/9 6/9 195 M ALI NGAR 72 M 90453 RE CF @2 mt s PHACO NIL NIL 6/12 6/9 6/9 6/6 -0.75DC 90" ATR
196 MUNIGANGAM M A 66 F 85213 RE HMCF PHACO Nil NIL 6/9 6/9 6/9 6/6 -0.5D5 -0.5DC 90• ATR
197 RAMESH GOWDA 59 M 94321 LE CF@ 1 mt PHACO NIL NIL 6/18 6/12 6/12 6/9 -0.25DS -0.25DC 90• ATR
198 VEKATESH SHETTY 53 M 30095 RE 6/24 PHACO Nil NIL 6/9 6/9 6/9 -199 YELLAM MA 67 F 67043 LE HMCF PHACO NIL NIL 6/12 6/12 6/9 . 200 PUTTACHARYA 85 M 77349 LE Pl PR + ve PHACO NIL CORNEAL EDEMA HMCF CF@l cf@ 1
mt mt
112
103
ANNEXURES
SURGICAL STEPS OF MSICS
FIGURE 20: CONJUCTIVAL FIGURE 21:SCLERO CORNEAL
PERITOMY TUNNEL
FIGURE 22 SIDE PORT FIGURE 23: TRYPHAN
BLUE STAINING OF AC
104
FIGURE 24: CAPSULORHEXIS FIGURE 26: NUCLEUS REMOVAL
FIGURE 25: KERATOME ENTRY FIGURE 27: RIGID IOL
IMPLANTATION
105
SURGICAL STEPS –PHACOEMULSIFICATION
FIGURE 28: SIDE PORT ENTRY FIGURE 29:TRILAMINAR
INCISION
FIGURE 30:STAINING OF AC FIGURE 31:CAPSULORHEXIS
WITH TRYPHAN BLUE
106
FIGURE 32: MAKING OF FIGURE33: IRRIGATION
TRENCH AND ASPIRATION
FIGURE 34: DIVIDE AND FIGURE 35: FOLDABLE IOL
CONQUER INJECTION