Reduction in astigmatism in manual small incision cataract surgery through change of incision site

Enlargement of main corneal incision: clinical intraindividual comparison of two preloaded intraocular lens injectors

PURPOSE

To compare the enlargement of the clear corneal incision from IOL implantation with 2 different intraocular lens (IOL) injectors: the AutonoMe preloaded with the Clareon IOL and the Multisert preloaded with the Vivinex IOL.

SETTING

The David J. Apple Center for Vision Research, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany.

DESIGN

Prospective randomized clinical comparative study.

METHODS

96 eyes of 48 patients with cataract were intraindividually randomized to treatment with 1 of the 2 injectors. For Multisert eyes, the insert shield (IS) was used in the advanced position in 23 eyes. The initial incision was 2.2 mm, and intraoperative measurements of the incision size were made before and after IOL injection. 3 months postoperatively, keratometry and uncorrected (UDVA) and corrected (CDVA) distance visual acuities were assessed.

RESULTS

Results are reported for 96 eyes of 48 patients. The mean incision enlargement was 0.213 ± 0.068 mm in the Multisert with the IS group, 0.265 ± 0.055 mm in the fellow eyes (AutonoMe) ( P < .05), 0.272 ± 0.060 mm in Multisert eyes treated without the IS, and 0.296 ± 0.066 mm for the fellow eyes (AutonoMe) ( P > .05). The mean absolute surgically induced astigmatism was 0.42 ± 0.23 diopters (D), 0.50 ± 0.25 D, and 0.44 ± 0.18 D in the Multisert with the IS, Multisert without the IS, and AutonoMe group, respectively ( P > .05). The UDVA and CDVA were comparable in all groups.

CONCLUSIONS

The Multisert was associated with less wound enlargement than the AutonoMe. All groups had comparable functional outcomes. Therefore, the observed difference in incision enlargement may be of limited clinical relevance.

Refractive Outcome of Cataract Surgery Done at University of Gondar Tertiary Eye Care and Training Center, North West Ethiopia

PURPOSE

According to World Health Organization (WHO), cataract is the leading cause of blindness and visual impairment throughout the world. Post-operative refractive error is one of the commonest reasons for poor visual outcome after cataract surgery especially in developing countries where the standard modern biometry equipments are not available. The objective of this study was to assess the refractive outcome of cataract surgery done at University of Gondar (UoG) Tertiary Eye Care and Training Center, North West Ethiopia.

METHODS

A descriptive cross-sectional study was done on 66 patients who had undergone manual small incision cataract surgery (MSICS) and fulfilled the inclusion criteria at UoG Tertiary Eye Care and Training Center from July 15 2019 to October 15 2019.

RESULTS

From 90 post-operatively refracted eyes, 58 (64.4%) eyes achieved a target refraction of ±1.00 Diopter (D). The right and left eyes achieved mean post-operative refraction SE of -0.073±1.45D and -0.93±1.70 D, respectively. But only 54 (60%) eyes were implanted with the calculated IOL power and for the remaining 40% the calculated IOL was not available at the store. And the target (Good) post-operative uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) was achieved in 66.7% and 82.2% eyes, respectively.

CONCLUSION

The post-operative refractive outcome after cataract surgery at the center is low. For over one-third of operated eyes, the calculated IOL was not implanted due to the absence of the required IOL power at the store and, therefore, a wide range of IOL power should be available at the center.

Surgically induced astigmatism and coupling effect-mediated keratometric changes after conventional phacoemulsification cataract surgery

Background

The aim of the present study was to describe surgically induced astigmatism (SIA) and the coupling effect after conventional phacoemulsification cataract surgery (CPS) in relation to the incisional axis.

Material and methods

A total of 42 patients were included in the retrospective case series study. Corneal topography was obtained for patients with significant cataract before and 6 weeks after CPS with a main clear corneal incision size of 2.4 mm. Patients were grouped according to the relationship of the incisional axis to the position of the steep axis into a steep incisional group and a flat incisional group.

Results

In total, 46 eyes were included in the study. While the steep incisional group showed an SIA of −0.15 D (± 0.35), the flat incisional group had a significantly higher SIA of 0.20 D (± 0.51) (p = 0.03). The coupling ratio (CR) in the steep incisional group was −0.38 (± 1.41) and in the flat incisional group it was 0.16 (± 0.97). Correspondingly, a coupling constant (CC) of −0.25 was found for group 1 and a CC of 0.0 for group 2.

Conclusion

Our results suggest that the location of the main incision should be decided with consideration of the corneal astigmatism in order to minimize the SIA. The CR helps to understand the effect of induced astigmatism and the change in spherical equivalent.

Assessment of a software guided system to reduce pre-existing astigmatism in cataract surgery

The aim of this pilot study was to assess the astigmatism after small incision cataract surgery by use of a novel software guided surgical technique. The software system guides the surgeon toward a hypothetical shape of the cornea. When this shape is achieved, the vertical meridian is relaxed and the incision does not produce any astigmatism. How that hypothetical shape is to be achieved by the surgeon is described. If preoperative astigmatism exists, the hypothetical shape calculated by the system takes that into account. This enables the surgeon to reduce preexisting astigmatism, without having to change the site or size of the standard 6 mm 12 o clock incision of SICS. Results: Results indicated that preoperative astigmatism reduced in 11 out of 14 cases at the end of 8 weeks, remained unchanged in one, and increased by less than 0.5D in two cases. This proves the hypothesis that the vertical corneal meridian is under higher tension and relaxing it by flattening the perpendicular meridian has a reducing effect on postoperative astigmatism.

Efficacy of intracameral antibiotics following manual small incision cataract surgery in reducing the rates of endophthalmitis: A meta-analysis

BACKGROUND

Manual small incision cataract surgery (MSICS) is a widely used technique for cataract surgery in the developing world. Higher rates of postoperative endophthalmitis have been reported with this technique compared with phaco-emulsification. The purpose of this study was to evaluate the efficacy of prophylactic intracameral (IC) antibiotics in reducing the rates of postoperative endophthalmitis following MSICS.

METHODS

Systematic review and meta-analysis of patients undergoing MSICS. A literature search in PubMed and EMBASE databases was performed to identify studies published from October 1992 to April 2020 evaluating MSICS with a minimum of 500 eyes reported. Two authors independently assessed eligibility, extracted data and assessed the risk of bias. Heterogeneity was assessed using the I² test.

RESULTS

Twelve studies enrolling 1 494 307 eyes were included. IC antibiotics were used in 725 324 (48.5%) eyes. The risk ratio of developing endophthalmitis was 2.94 (95% CI, 1.07-8.12; P = .037) in eyes that did not receive IC antibiotics.

CONCLUSIONS

Routine use of IC antibiotics may help to reduce the rates of endophthalmitis following MSICS and significantly improve the safety of this effective form of cataract surgery.

Minimizing surgically induced astigmatism in non-phaco manual small incision cataract surgery by U-shaped modification of scleral incision

Purpose:

To evaluate the amount and type of surgically induced astigmatism (SIA) in manual small incision cataract surgery (SICS) with a 4.5 mm U-shaped scleral incision.

Methods:

A prospective cross-sectional study was done on a total of 61 patients above 40 years of age with senile cataract. All patients underwent complete examination including preoperative uncorrected visual acuity (UCVA), refraction, best-corrected visual acuity (BCVA), and keratometry using a manual keratometer (Bausch and Lomb). All 61 patients underwent manual SICS with a 4.5 mm U-shaped scleral incision within the astigmatic neutral incisional funnel. Patients were thoroughly examined on immediate postoperative day 1 and findings of UCVA, BCVA, refraction, and keratometry were noted at the end of the 1^st week, 4^th week, and 6^th week follow-up visits. SIA was calculated for all the follow-ups using the SIA calculator version 2.1, a free software program. The changes in the amount and type of postoperative SIA were tested for statistical significance using Fischer's exact test. Variance was tested using intraclass score effect. The threshold for statistical significance was set to P < 0.001.

Results:

Postoperatively, the average SIA was 0.43 ± 0.13 D at the end of 1^st week, 0.29 ± 0.20 D at the end of the 4^th week, and remained the same 0.29 ± 0.21 D at the end of 6^th week. The type of astigmatism shifted more towards against-the-rule (ATR) type in 45.9% of cases during the final postoperative follow-up.

Conclusion:

In our study, we conclude that the incision within the funnel of astigmatic neutralization is one of the major determinants of SIA in manual SICS. We were able to achieve phacocomparable SIA in our study mainly because of our type of incision.

Review of manual small-incision cataract surgery

Cataract surgery has undergone many changes with the size of incision progressively decreasing over time with an incision of 12.0 mm for intracapsular cataract extraction to 2.2–2.8 mm in phacoemulsification. However, phacoemulsification due to high cost and equipment maintenance cannot be employed widely in developing countries. Manual small-incision cataract surgery (MSICS) offers similar advantages with the merits of wider applicability, less time consuming, a shorter learning curve, and lower cost. MSICS can be performed in high-volume setups due to fast technique. Here, we review the various techniques, safety and efficacy of MSICS, and its progress and utility in developing and underdeveloped countries.

[Phacoemulsification versus manual small incision cataract surgery: Anatomic and functional results]

PURPOSE

Prospective randomised study to compare the impact of phacoemusification (PHACO) and small incision cataract surgery (SICS) on endothelial structure (cell density and morphology) and refractive results (visual acuity, induced astigmatism).

METHODS

Prospective study of 57 patients (63 eyes) over 20 months (May 2012-January 2014) undergoing surgery by 2 experienced surgeons. We included patients with senile or presenile cataracts, LOCS III class 2, 3 and 4. Patients were randomized into 2 groups based on their birth month (group 1: PHACO [33]; group 2: SICS [30]). All pre- intra- and postoperative data were collected prospectively. The minimum follow-up was 6 months. We used the SPSS 18.0 for statistical analysis. Statistical tests used included the test-t Student, the Anova test, the Mann-Witney non-parametric test and the Khi² test. A threshold of significance was set at 0.05.

RESULTS

The mean preoperative endothelial cell density was 2447.5±225 c/mm² with no significant difference between the two groups (P=0.207). The mean percentage of hexagonality was 55.5±8.2% in groups 1 and 2. The most significant cell loss was during the first immediate postoperative period for both groups. At Day 15 postoperative, the decrease in cell loss was significant (P<0.001) with a mean loss of 312.9±208.9 c/mm² (P<10^-2). Postoperatively, the mean best-corrected visual acuity was 0.057 log MAR for all of our patients (P=0.170); no patient had an acuity ≤1/10. The mean astigmatism at the conclusion of follow-up was 1.08±0.42 D in group 1 and 1.51±0.55 D in group 2, with a significant difference (P=0.001).

CONCLUSION

Both SICS and PHACO give excellent results, both anatomical and refractive. However, SICS appears to be more advantageous than PHACO in terms of speed, cost, and independence from technology, and appears to be better suited to dense cataracts and mass surgery.

Minimal duration cataract surgery with oblique limbal stab incision technique

PURPOSE:

Small incision cataract surgery (SICS) and phacoemulsification with oblique limbal stab incision technique were studied and compared.

SETTING:

The study was conducted in the Department of Ophthalmology, Indira Gandhi Medical College, Shimla, for 1 year.

DESIGN:

This was a prospective randomized study.

METHODS:

One hundred patients undergoing SICS (6–7 mm) were compared with another age- and sex-matched 100 patients undergoing phaco (2.8 mm) surgery with oblique limbal stab incision technique. These two groups were further subdivided into two groups of 50 each. Patients with traumatic cataract, corneal diseases, and preoperative astigmatism >1.5 D were excluded from the study. The patients were subjected to standard preoperative evaluation. Follow-up was done at 1, 2, 4, 6, and 12 weeks.

RESULTS:

Mean surgically induced astigmatism at 12 weeks was <1 D in both groups (+0.62 D ± 0.34 in Group A and +0.46 D ± 0.39 in Group B) (statistically significant P < 0.0010). Mean surgical duration was 690.09 s in SICS and 792.29 s in phacoemulsification (statistically significant, P < 0.0010). Visual outcome was between 6/6 and 6/9 in 86% of the patients in Group A and 97% of patients in Group B at 12 weeks.

CONCLUSION:

SICS and phacoemulsification with this technique yield lesser astigmatism than clear corneal and scleral incisions, with the advantage of extension without suturing in complicated cases of phaco and in patients with rigid intraocular lens phacoemulsification gives better BCVA in a larger proportion of patients at 12 weeks.

Postoperative Corneal and Surgically Induced Astigmatism following Superior Approach Manual Small Incision Cataract Surgery in Patients with Preoperative Against-the-Rule Astigmatism

The aim of the study was to report postoperative corneal and surgically induced astigmatism (SIA) in patients with preoperative against-the-rule (ATR) astigmatism who underwent superior approach manual small incision cataract surgery (MSICS). 58 eyes of 58 cataract patients with preoperative ATR astigmatism were involved in this study. All patients had operable cataracts and underwent superior approach MSICS. Keratometric (K) readings were taken prior to surgery and at 12 weeks after surgery. Centroid values of SIA, preoperative astigmatism, and postoperative astigmatism were calculated using Cartesian coordinates based analysis. Wilcoxon signed rank test was used to compute statistical significance between mean preoperative and postoperative corneal astigmatism. Cohen's d was used as effect size measure. Centroid values of 1.42 D × 179, 2.48 D × 0, and 1.07 D × 1 were recorded, respectively, for preoperative astigmatism, postoperative astigmatism, and SIA. Wilcoxon signed rank test indicated that mean ± SD postoperative corneal astigmatism (2.80 ± 1.40 D) was statistically significantly greater than preoperative corneal astigmatism (1.49 ± 1.34 D), Z = −6.263, p < 0.0001. A high Cohen's d of 1.32 was found. Our results suggest statistical and clinically significant greater postoperative corneal astigmatism than preoperative corneal astigmatism for ATR astigmatism cataract patients who underwent superior approach MSICS.

Comparison of surgically induced astigmatism between horizontal and X-pattern sutures in the scleral tunnel incisions for manual small incision cataract surgery

Background:

Two types of popular scleral tunnel sutures in the manual small incision cataract surgery (MSICS) are horizontal and X-pattern sutures. Surgically induced corneal astigmatism (SIA) is a useful indicator of the suturing effect.

Aims:

To compare SIA between horizontal and X-pattern sutures in the scleral tunnel incisions for MSICS.

Design:

Prospective, nonrandomized comparative trial.

Materials and Methods:

After superior scleral tunnel incision and capsulorhexis, the nucleus was prolapsed into the anterior chamber and delivered. The wound was sutured with either horizontal or X-pattern suture. The simulated keratometry values were derived from the corneal topography preoperatively and 1.5 and 3 months postoperatively.

Statistical Analysis:

The SIA was calculated by Cartesian coordinates based analysis.

Results:

Sixty-four patients (32 patients in each group) were included in the study. In the horizontal suture group, the SIA centroid values at 1.5 and 3 months after the surgery were 0.87 × 1° and 1.11 × 180°, respectively, showing induction of against-the-rule astigmatism. In the X-pattern suture group, the SIA centroid values at 1.5 and 3 months after the surgery were 0.61 × 97° and 0.66 × 92°, respectively, showing induction of mild with-the-rule astigmatism. The difference between the amount of SIA at 1.5 and 3 months after surgery was small.

Conclusion:

In the MSICS, the X-pattern sutures were preferred to the horizontal sutures in the patients without significant preoperative steepening in line with the central meridian of the incision. In the cases with significant preoperative steepening, sutureless surgery or horizontal sutures were preferred. Corneal astigmatism in the patients undergoing MSICS was stable at 1.5 months after the surgery.

The location of incision in cataract surgery and its impact on induced astigmatism

PURPOSE OF REVIEW

The purpose of the present study is a systematic review of previous studies on choosing the best incision site for the correction of astigmatism in cataract surgery and assessing the amount of surgically induced astigmatism (SIA) with each approach.

RECENT FINDINGS

Regardless of astigmatism axis, studies show that using an on-axis incision is associated with favorable results for 0.5-1.0 diopter (D) of astigmatism. In cases with more than 1.0 D astigmatism, paired on-axis incisions can be appreciably efficient in astigmatism correction and cause at least 1.5 D SIA. Considering the amount of SIA, a temporal incision is the best approach when the patient has minimal amounts of corneal astigmatism preoperatively. At higher levels of astigmatism, if no other astigmatism correction method is used simultaneously, the temporal incision is used less frequently; however, since it is associated with the least SIA, it is still the choice site when another correction method is used.

SUMMARY

The temporal incisions in cataract surgery are associated with little SIA and are appropriate choices for mild preoperative astigmatism. At higher levels of preoperative astigmatism, superior incisions are associated with better results when combined methods are not applied.

Comparison of surgically induced astigmatism in various incisions in manual small incision cataract surgery

AIM

To determine the surgically induced astigmatism (SIA) in Straight, Frown and Inverted V shape (Chevron) incisions in manual small incision cataract surgery (SICS).

METHODS

A prospective cross sectional study was done on a total of 75 patients aged 40y and above with senile cataract. The patients were randomly divided into three groups (25 each). Each group received a particular type of incision (Straight, Frown or Inverted V shape incisions). Manual SICS with intraocular lens (IOL) implantation was performed. The patients were compared 4wk post operatively for uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA) and SIA. All calculations were performed using the SIA calculator version 2.1, a free software program. The study was analyzed using SPSS version 15.0 statistical analysis software.

RESULTS

The study found that 89.5% of patients in Straight incision group, 94.2% in Frown incision group and 95.7% in Inverted V group attained BCVA post-operatively in the range of 6/6 to 6/18. Mean SIA was minimum (-0.88±0.61D×90 degrees) with Inverted V incision which was statistically significant.

CONCLUSION

Inverted V (Chevron) incision gives minimal SIA.

Extra Large Temporal Tunnel Cataract Extraction [ETCE]

PURPOSE

To determine the outcomes of extra large temporal sclero-corneal tunnel incision Cataract Surgery.

MATERIALS AND METHODS

This consecutive case series of eyes undergoing temporal tunnel cataract extraction with tunnel length of 8 to 10 mm was identified retrospectively. Surgical procedure details, follow up, complications, visual and astigmatic outcomes at 6wks were recorded and analysed.

RESULTS

Ninety six eyes with extra large tunnel incision were identified for analysis from a dataset of 670 manual small incision cataract surgery cases. 58% eyes had NO5 or denser cataracts. Intraoperative complications included, tunnel related problems (1 eye, 1.04%), bleeding into Anterior Chamber (10 eyes, 10.4%), Posterior Capsular Rent (2 eyes, 2.1%). Early postoperative complications included striate keratopathy (7 eyes, 7.3%). The mean Best Corrected Visual Acuity was 6/7.5 (0.1 logMAR) and 98% cases had Best Corrected Visual Acuity of 6/12 (0.3 logMAR) or better at 6wk. The aggregate Surgically Induced Astigmatism was 0.32D at 85(0).

CONCLUSION

Extra Large Tunnel of length 8 to 10 mm can be self sealing with low SIA. The complication rates and visual outcomes of ETCE are comparable to those of conventional MSICS. This method can be valuable in complicated cases and during learning period.

Combined Topical-Intracameral Anesthesia in Manual Small-Incision Cataract Surgery: A Prospective, Randomized, Double-Masked, Placebo-Controlled Trial

PURPOSE

To determine whether intracameral lidocaine plus topical anesthesia could further reduce patients' pain experience during manual small-incision cataract surgery, compared with topical anesthesia alone.

DESIGN

A prospective, randomized, double-masked, placebo-controlled clinical trial was conducted.

METHODS

This research was approved by the institutional review board of the Eye Hospital of Wenzhou Medical College in China. All patients gave written, informed consent, and no untoward pressure or coercion was used for the written informed consent. A total of 300 patients were randomly assigned into the placebo group (topical anesthesia plus intracameral balanced salt solution) or the interventional group (combined topical plus intracameral anesthesia). The pains they experienced during the different stages of the operation were evaluated by a visual analog pain scale. At the end of the surgery, the surgeon was given a questionnaire to evaluate the cooperation of the patient. The endothelial cell count was collected preoperatively and 1 month postoperatively.

RESULTS

The patient-reported pain scores were significantly lower in the interventional group at the following stages of the operation: nucleus rotation (P < 0.001), bisection of the nucleus (P < 0.001), and prolapse of the nucleus (P < 0.001). The surgeon assessment showed better patient cooperation in the lidocaine group (P = 0.04). There was no significant difference in endothelial cell loss between the 2 groups.

CONCLUSIONS

Although topical anesthesia alone provides acceptable anesthesia for manual small-incision cataract surgery, combined topical and intracameral anesthesia decreased patients' discomfort and increased their cooperation during the operation.

Smaller Incision Size Leads to Higher Predictability in Microcoaxial Cataract Surgery

Purpose.

The aim of the study was to compare the clinical outcomes of a 1.8 mm, 2.2 mm, and 2.75 mm microcoaxial cataract surgery system.

Methods.

In this retrospective study, 129 eyes of 129 patients were included. Patients underwent phacoemulsification using a Stellaris system or an Infiniti system. The incision size was 1.8 mm, 2.2 mm, or 2.75 mm, respectively. Subjects were examined before surgery and 4 weeks after. The surgically induced astigmatism (SIA) was examined.

Results.

The SIA in the 1.8 mm group was statistically lower compared to the 2.2 mm group (p=0.046) and the 2.75 mm group (p=0.017). There was no significant difference between the 2.2 mm group and the 2.75 mm group.

Conclusions.

With the use of appropriate support systems, 1.8 mm incisions appear to result in less SIA than 2.2 mm and 2.75 mm incisions. Advantages may arise from this, especially in the implantation of aspheric, toric, or multifocal lenses.

[Cataract surgery outcomes by temporal small incision techniques with and without phacoemulsification. Results of a prospective study from Kenya]

BACKGROUND

The present outcomes of cataract surgery in Africa do not meet the recommendations of the World Health Organization. Superior manual small incision cataract surgery (SICS) is the operation of choice in many developing countries. However, there is good evidence that temporal incisions are more stable and cause less surgically induced astigmatism (SIA).

METHODS

In a prospective, non-randomized study in an anterior segment clinic in the southeastern part of Kenya, 405 eyes were operated on using either temporal phacoemulsification (n = 288) or temporal SICS (n = 117) with implantation of a rigid intraocular lens (IOL). The main outcome variables were preexisting corneal astigmatism, SIA, visual outcomes and complication rates.

RESULTS

Preoperatively, the mean astigmatism in all eyes was 1.1 diopters (D) ranging from 0 to 6.28 D. Against-the-rule astigmatism (ATR) (mean 1.18 D) was most common with 60.4%. After 8 weeks following surgery the mean SIA was 1.13 D (SD ±0.63 D) at 92° for phacoemulsification and 1.11 D (SD ±0.56 D) at 102° for SICS. Of the eyes 89.6% reached a best corrected visual acuity (BCVA)  ≥ 0.3 and 82.7% reached this visual acuity also uncorrected. The main reasons for not reaching BCVA ≥ 0.3 were ocular comorbidities.

CONCLUSIONS

In the population studied most patients had preexisting ATR astigmatism and a switch to routine temporal incisions appeared beneficial. The World Health Organization recommends that poor (BCVA below 0.1) or borderline (BCVA below 0.3) outcomes after cataract surgery should not be more than 10-20%. This goal has been achieved in this study with the techniques presented.

The influence of corneal wound size on surgically induced corneal astigmatism after phacoemulsification

BACKGROUND/PURPOSE

To determine whether there is a difference in surgically induced astigmatism (SIA) after phacoemulsification for unsutured temporal clear corneal incisions of 2.5 mm and 3.5 mm wound sizes.

METHODS

This study comprised 36 eyes of 18 patients who received cataract surgery from a single surgeon. Patients were randomly assigned to receive a one-piece intraocular lens (IOL; Acrysof SA60AT), through a 2.5 mm incision in one eye, and a three-piece IOL (Tecnis Z9000), through a 3.5 mm incision in the contralateral eye. Corneal topography was performed preoperatively and also postoperatively at 3, 6, and 12 weeks. SIA was calculated by means of vector analysis using the Alpins' method.

RESULTS

The mean SIAs of the groups with 2.5 mm and 3.5 mm incisions were 0.57 diopter (D) and 0.86 D respectively (p = 0.04) at 3 weeks postoperatively, 0.60 D and 0.83 D respectively (p > 0.05) at 6 weeks postoperatively, and 0.58 D and 0.58 D respectively (p > 0.05) at 12 weeks postoperatively. At 12 weeks postoperatively, SIAs of <1.0 D were found in all eyes in the 2.5 mm group and 93% of eyes in the 3.5 mm group. Forty-four percent of eyes in both groups demonstrated SIAs > 0.5 D at 12 weeks postoperatively. The largest SIA was 1.36 D in the 3.5 mm group.

CONCLUSION

Mean SIA in the 3.5 mm group was larger than that in the 2.5 mm group in the early postoperative period, but there was no significant difference for the entire observational period.

Safety and efficacy of temporal manual small incision cataract surgery in India

PURPOSE

To assess safety and efficacy of temporal manual small incision cataract surgery (SICS) in context to visual outcome, astigmatism, and complications.

METHODS

This involved sclerocorneal tunnel, capsulotomy, and hydrodissection. The incision was made with number 11 disposable surgical blade (costing Indian Rs. 2.50, $0.05). Nucleus extraction was done by phaco-sandwich method with the help of vectis and dialer. Posterior chamber intraocular lens implantation was done according to biometric findings. A record of intraoperative and postoperative complications was made. The final postoperative assessment of astigmatism was done with spectacle correction on the 45th day as per the refraction findings.

RESULTS

Two thousand eyes were operated by temporal, manual small incision sutureless technique. Uncorrected visual acuity was >6/18 in 1636 (81.7%) patients on the first postoperative day, in 1652 (82.6%) patients at 2 weeks, and in 1732 (88.6%) patients at 6 weeks. Best-corrected visual acuity (BCVA) >6/18 was achieved in 1868 (93.4%) patients at 6 weeks, with 46 (2.3%) having BCVA <6/60, 24 (1.2%) of whom had preexisting retinal pathology. At 6 weeks, 1876 (93.8%) eyes had with-the-rule and 134 (6.2%) against-the-rule astigmatism (mean 0.7±1.25 D). Iris prolapse was noted in 3 (0.15%), wound leak in 3 (0.15%), and transient corneal edema in 136 (6.8%) eyes. Average surgery time was 6 minutes.

CONCLUSIONS

Temporal SICS with number 11 disposable surgical blade and nucleus delivery by phaco-sandwich method gave excellent outcome with minimal astigmatism and low complication rate at economic cost.

Manual Small Incision Cataract Surgery: A Review

We aim at reviewing published peer-reviewed studies that evaluate the safety and efficacy of manual small incision cataract surgery (MSICS). Literature searches of the PubMed and the Cochrane Library databases were conducted with no date restrictions; the searches were limited to articles published in English only. All publications with at least level II and III evidence were studied and surgical techniques were analyzed. MSICS was also compared with phacoemulsification and large incision extracapsular cataract surgery (ECCE) with respect to visual outcome, surgery time, cost, intra and postoperative complications and suitability for high volume surgical practices in the developing world.The overall safety profile of MSICS was found to be excellent with intra and postoperative complication rates comparable to phacoemulsification and ECCE. Multiple studies reported the safety and efficacy of MSICS for complicated cases, such as brunescent and white cataract and cataracts associated with phacolytic and phacomorphic glaucoma. Compared to phacoemulsification MSICS was associated with lower and shorter operative times. Visual outcomes were excellent and comparable to phacoemulsification with up to 6 months follow up.The literature provides outcome analysis of a variety of different MSICS techniques. As a whole, MSICS provides excellent outcomes with a low rate of surgical and postoperative complications. Particularly in the developing world, MSICS appears to provide outcomes that are of comparable quality to phacoemulsification at a much lower cost.

Cataract surgery in developing countries

PURPOSE OF REVIEW

To review the previous year's literature related to cataract surgery in developing countries and to provide fast, up-to-date information to the scientific world.

RECENT FINDINGS

Cataract is the leading cause of blindness, especially in developing countries. The prevalence of cataract increases with the aging population. Although cataract surgery is the most cost-effective intervention, its delivery in developing countries has many issues and challenges. A paradigm shift has occurred in the surgical techniques used for delivering cataract services and the outcomes have been positive in some countries compared to the scenario a decade ago. However, in some parts of Africa, it still continues to be a challenge. Apart from this, the issues related to ongoing supply of consumables and human resources continue to be a challenge in these countries.

SUMMARY

Although manual small incision cataract surgery is the most cost-effective intervention, there are other issues related to the delivery of services in developing countries. We need to plan a comprehensive strategy to deliver the services in developing countries if we want to achieve our goal of VISION 2020.

Small incision cataract surgery: Complications and mini-review

This article reviews the literature on manual small incision cataract surgery (MSICS) and its complications. Various articles on MSICS published in indexed journals were reviewed, as well as the sections on complications of MSICS. The Pubmed search engine on the Internet was used to find out articles published since 1985 on MSICS in any language in indexed journals. Books published by Indian authors and the website of Indian Journal of Ophthalmology were also referred to. MSICS has become very popular technique of cataract surgery in India, and it is often used as an alternative to phacoemulsification. Studies on its efficacy and safety for cataract surgery show that, being a variant of extracapsular cataract surgery, MSICS also has similar intraoperative and postoperative complications. The considerable handling inside the anterior chamber during nucleus delivery increase the chances of iris injury, striate keratitis, and posterior capsular rupture. The surgeon has to be extra careful in the construction of the scleral tunnel and to achieve a good capsulorrhexis. Postoperative inflammation and corneal edema are rare if surgeons have the expertise and patience. The final astigmatism is less than that in the extracapsular cataract surgery and almost comparable to that in phacoemulsification. There is, however, a concern of posterior capsular opacification in the long term, which needs to be addressed. Although MSICS demands skill and patience from the cataract surgeon, it is a safe, effective, and economical alternative to competing techniques and can be the answer to tackle the large backlog of blindness due to cataract.

Nucleus management in manual small incision cataract surgery by phacosection

Nucleus management is critical in manual small incision cataract surgery (MSICS), as the integrity of the tunnel, endothelium and posterior capsule needs to be respected. Several techniques of nucleus management are in vogue, depending upon the specific technique of MSICS. Nucleus can be removed in toto or bisected or trisected into smaller segments. The pressure in the eye can be maintained at the desired level with the use of an anterior chamber maintainer or kept at atmospheric levels. In MSICS, unlike phacoemulsification, there is no need to limit the size of the tunnel or restrain the size of capsulorrhexis. Large well-structured tunnels and larger capsulorrhexis provide better control on the surgical maneuvers. Safety and simplicity of MSICS has made it extremely popular. The purpose of this article is to describe nucleus management by phacosection in MSICS.