30 Vol. 32, No. 1, Jan – Mar, 2016 Pakistan Journal of Ophthalmology Original Article Anterior Chamber Depth Changes after Uneventful Phacoemulsification Mustafa Kamal Junejo, Tanveer Anjum Chaudhry Pak J Ophthalmol 2016, Vol. 32, No. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Mustafa Kamal Junejo Instructor Ophthalmology Section of Ophthalmology, Department of Surgery Aga Khan University, Karachi, Pakistan E-mail: mkjunejo@yahoo.com Received: October 30, 2015 Accepted: April 10, 2016. …..……………………….. Purpose: To measure changes in anterior chamber depth (ACD) after uneventful cataract surgery through phacoemulsification along with intraocular lens (IOL) implantation in healthy eyes using ultrasonography (Amplitude Scan). Study Design: Prospective observational clinical case series. Place and duration of Study: Section of Ophthalmology, department of surgery, Aga Khan University Hospital Karachi Pakistan from September 2011 to March, 2012. Material and Methods: Seventy Four eyes (74 patients) underwent Ultrasonography A Scan to evaluate anterior chamber configuration before, 1 day after, 1 week after and 1 month post-operative. We measured central ACD. Pre-operative and post-operative data was compared by using paired t tests. Results: A total of 74 subjects were enrolled in this study. There were 42 males (56.8%) and 32 females (43.2%).Before surgery, overall mean anterior chamberdepth (mm) ACD was 3.02 ± 0.43; in males was 3.07 ± 0.43 and in females was 2.96 ± 0.43. Overall, the mean ACD after 1 day of cataract surgery 3.46 ± 0.44,after 1 week of surgery was 3.64 ± 0.46, and after 1 month of surgery was 3.81 ± 0.46.Significant increase of 0.73 ± 0.58mm (p < 0.0001) in the mean ACD was seen after 1 month of surgery. However , mean difference in ACD after 1 month of surgery between male and female groups was 0.11 ± 0.09; which was not statistically significant (p = 0.42). After uneventful phacoemulsification along with IOL implantation, the anterior chamber angle depth increased markedly. Conclusion: Following uneventful phacoemulsification along with Intraocular lens implantation, the ACD markedly increased which, was statistically significant. Ultrasound A Scan is simple and easily available tool for obtaining quantitative data about anterior chamber depth. Keywords: Cataract, Anterior Chamber Depth, Phacoemulsification, Ultrasonography A Scan. INTRODUCTION ataract surgery is the most common surgical procedure done worldwide. In phacoemulsification cataractous lens is extracted after lens is crushed by ultrasound waves and then suctioned out of the capsule and intraocular lens (IOL) is implanted in capsule to obtain good visual acuity post operatively.1 Theoretical formulas for the calculation of axial length, IOL power calculation and Anterior chamber depth measurements has been evolving for the better outcomes of cataract surgery.SRK/T being one of the older formulas measures only axial Length (AL), keratometry and Anterior Chamber depth (ACD) which is calculated from the corneal curvature as compared to newer formulas which involve C mailto:mkjunejo@yahoo.com ANTERIOR CHAMBER DEPTH CHANGES AFTER UNEVENTFUL PHACOEMULSIFICATION Pakistan Journal of Ophthalmology Vol. 32, No. 1, Jan – Mar, 2016 31 measurements of anterior chamber depth preoperatively which, predicts the postoperative effective lens position (ELP) and postoperative refraction indirectly.1,2 Cataract extraction with intraocular lens (IOL) implantation results in widening of the anterior chamber angle and depth to deepen in healthy and especially in glaucomatous eyes.3 Advanced imaging studies have proven that crystalline lens pushes the peripheral iris anteriorly and hence causes narrowing of anterior chamber angle particularly in cataractous lenses.4 Several methods have been used in previous studies to calculate anterior chamber depth after cataract surgery. The object of this study was tomeasure changes in the anterior chamber depth after uneventful phacoemulsification with IOL implantation in healthy eyes using A Scan. We gathered quantitative data from normal Pakistani eyes as measured by A Scan Ultrasound and standardized parameters of anterior chamber were compared. MATERIALS AND METHODS This prospective observational clinical case series study conducted at section of Ophthalmology, department of surgery, Aga Khan University Hospital Karachi Pakistan from September 2011 to March, 2012comprised of 74 eyes from 74 consecutive patients who underwent cataract surgery from September 2011 to December 2011. Patients Age, Gender and Eye whether right or left were kept under consideration for the study.Axial lengths were obtained using A- Scan. Single examiner took measurements of all patients on different visits. Anterior chamber depth measurements were taken on once pre-operative visit and thrice on post-operative visits i.e. 1 day, 1 week and 1 month post-operatively. Verbal consent was taken from all patients who participated in this study. Patients who consented for procedure. Those whose Intra ocular lens was implanted in the capsular bag and those patients who completed all postoperative follow up visits were included in this study. A thorough eye examination was performed pre operatively. The visual acuity was measured using the Snellen’s chart. Nuclear grading (1 to 4) was performed using a cobalt blue filter light and the type of cataract (cortical, nuclear, posterior sub capsular and polar) was noted by slit lamp biomicroscopy. Keratometric values were measured with a Javalkeratometer, and mean of 2 values taken from the main axis was calculated. The axial length was measured with A-scan ultrasonography and IOL power calculation by the SRK T and Holladay formulas corresponding to respective axial lengths. Posterior segment examination was done with +90.0 diopter lens in eyes without dense cataract. B-scan ultrasonography was used in those patients whose posterior segment examination was not possible due to their dense cataracts. The ACD was measured by A- scan ultrasonography the day before surgery and 1 day, 1 week, and 1 month postoperatively by same examiner. Average of the four consecutive measurements was calculated and used in the study. Surgery was performed using topical anaesthesia with propracaine hydrochloride (63 eyes; 85%) and retrobulbaranaesthesia with xylocaine 2% (11 eyes; 15%). The same surgeon performed all surgeries. A 3 – plane clear corneal incision was made in the steep meridian. A capsulorrhexisranging from 4.0 mm to 5.0 mm was made with cystotome, and cortical-cleaving, hydro dissection and hydro delineation were performed. The nucleus was sculpted and emulsified through Stop-and-Chop and Divide and Conquer techniques. After cortical clean up, an injectable acrylic aspheric IOL with a 6.0 mm optic and 12.5 mm haptic diameter was implanted in the bag. The incisions were not sutured. Postoperatively, patients were prescribed topical antibiotics and topical steroids as 01 hourly on the day of surgery, 02 hourly on 1st post-operative day and tapered down in 4 weeks on weekly basis as QID, TID and BID, then stopped. Statistical Analysis was done on SPSS version 19.0 for Windows. Frequencies and percentages were calculated for categorical variables like gender and age groups; and median were computed for numerical variables like age. Tables and charts were used to present the results. Paired t-test was used to compare means pre and post operatively. Independent t –test was performed to compare ACD changes between gender groups. P < 0.05 was considered to be statistically significant. RESULTS Total of 74 eyes were recruited in this study {male= 42 (56.8%), female = 32 (43.2%)}. 64.9% eyes were of right side with frequency and percentage of 48 and 64.9%,remaining one (left sided) with frequency and percentage of 26 and 35.1%. 51 patients (68.9%) of our study population were myopic and remaining 23 patients (31.0%) were hypermetropic (Table 1). MUSTAFA KAMAL JUNEJO, et al 32 Vol. 32, No. 1, Jan – Mar, 2016 Pakistan Journal of Ophthalmology Table 1: Characteristics of the study population n= No. of Eyes. Age (years) Frequency Percent Mean 59.7 ± 7.9 n = 74 100% Gender Male 42 56.8 Female 32 43.2 Eye Right 48 64.9 Left 26 35.1 Refractive Error Myopia 51 68.9 Hypermetropia 23 31.0 Patient Flow chart N = 103 First Post Op: Visit 96 Patients 7 lost to follow Second Post Op Visit 78 Patients 18 lost at 1 week Final Post Op visit 74 Patients Figure 1: Flow chart of Patients showing number of patients who lost to follow during postoperative visits. Table 2: Mean anterior chamber depth (ACD) after cataract surgery (n = 74 eyes). AC Depth (mm) Gender Mean Std. Deviation Number of subjects Before surgery Male 3.07 0.43 42 Female 2.96 0.43 32 Overall 3.02 0.43 74 1 day after surgery Male 3.45 0.48 42 Female 3.47 0.40 32 Overall 3.46 0.44 74 1 week after surgery Male 3.67 0.51 42 Female 3.60 0.39 32 Overall 3.64 0.46 74 1 month after surgery Male 3.83 0.49 42 Female 3.77 0.43 32 Overall 3.81 0.46 74 According to table 2 mean and standard deviation were measured gender wise. Mean anterior chamber depth (ACD) before surgery, 1 day after surgery, 1 week after surgery and 1 month after surgery in male was 3.07 ± 0.43, 3.45 ± 0.48, 3.67 ± 0.51 and 3.83 ± 0.49. Similarly Mean anterior chamber depth in females was 2.96 ± 0.43, 3.47 ± 0.40, 3.60 ± 0.39 and 3.77 ± 0.43 with overall Mean of 3.02 ± 0.43, 3.46 ± 0.44, 3.64 ± 0.46 and 3.81 ± 0.46. There was statistically significant increase in the mean ACD, from 3.02 ± 0.43mm preoperatively to 3.81 ± 0.46mm 1 month after surgery (p < 0.0001); an increase of 0.73 ± 0.58mm. However, when mean ACD one month after surgery was compared between male (3.83 ± 0.49 mm) and female (3.77 ± 0.43mm) groups, no statistically significant difference was found (p = 0.42). ANTERIOR CHAMBER DEPTH CHANGES AFTER UNEVENTFUL PHACOEMULSIFICATION Pakistan Journal of Ophthalmology Vol. 32, No. 1, Jan – Mar, 2016 33 DISCUSSION According to this study uneventful Phacoemulsification with in the bag injectable intraocular lens implantation widens the anterior chamber angle and increases anterior chamber depth by pushing back the iris lens diaphragm. Advantage of anterior chamber depth after phacoemulsification with intra ocular lens implantation surgery is that deep postoperative anterior chamber facilitates aqueous drainage more as compared to anterior chamber with normal lens in human eyes. Most of the subjects with ocular hypertension before cataract surgery absolutely get normal IOP levels after cataract surgery and doesn’t require management anymore.1-4 In this prospective clinicalcase series study 103 patients were enrolled for the study but only 74 patients followed till last visit. It means 103 patients got measured their anterior chamber depth preoperatively and lost to follow up were 29 patients. To the best of author’s knowledge no one has conducted this study in Pakistani population and the purpose of this study is to calculate that how much percent anterior chamber depth increases after uneventful phacoemulsification and IOL implantation. The overall increase in mean anterior chamber depth of 74 patients after 4 weeks of surgery was 790 microns which is evident with other studies as well1,2. There was increase in overall anterior chamber depth of 440 microns 1 day after surgery, 620 microns one week after surgery, followed by overall increase in anterior chamber depth of 740 microns after one month of surgery (table 2). Other studies have demonstrated increase in anterior chamber depth in normal population after phacoemulsification by measuring depth by different methods like Scheimpflug or ultrasound biomicroscope imaging methods.4 Hayashi et al found out by Scheimpflug imaging that width and depth of anterior chamber angle increased significantly i.e. 39.7% after cataract extraction followed by IOL implantation.4-8 However increase in Anterior chamber depth in this study is somehow less i.e. 26.1% than reported by other investigators which may be possibly that our group of patients were more myopic than others as it has been reported that hypermetropes show more change in anterior chamber depth than myopes. Difference between our study and study conducted by Dooley et al, is that refractive status of patients were not measured in our study but mean age of most of the patients in both the studies was 69 years, other major difference between the two studies is of ethnic groups that in our study all patients are Asians as compared to white Caucasians in the study of Dooley et al.5-12 Nonaka et al, reported that lens plays important role in pathogenesis of primary angle closure glaucoma because of its anatomic features like lens thickness which increases with age, with cataractous changes and relatively its anterior positioning, hence he proved that lens extraction would widen the anterior chamber angle and therefore resolve pupillary block glaucoma.4,6-8 Postoperative capsular shrinkage and IOL positioning also alters anterior chamber depth. Previous studies have shown change in anterior chamber depth with different types of IOL designs and types.9-12 Matsuura et al in 1989 also have reported that anterior chamber depth increased after cataract extraction and IOL implantation. Some other investigators reported rather shallowing of anterior chamber (Yoshida et al 1989).10,-17 Thill – Schwaninger and Giers in 1989 suggested that anterior chamber depth depends upon different shapes of IOL haptics.10,-20 Other techniques should be used to calculate change in anterior chamber depth and complete morphology. We only measured Anterior chamber depth through Ultrasound A scan so this is being the limitation of our study because for proper Anterior chamber assessment we need to assess all the parameters such as anterior chamber angle, volume, central and peripheral depths and last but not the least complete corneal topography through Anterior SegmentOCT. CONCLUSION This study proves that anterior chamber depth increases approximately 26% after uneventful cataract surgery with intra ocular lens in capsular bag implantation which, helps in aqueous drainage by pushing back iris lens diaphragm and widening the anterior chamber angle, hence prevents improper diagnosis and unnecessary treatment of glaucoma entities. MUSTAFA KAMAL JUNEJO, et al 34 Vol. 32, No. 1, Jan – Mar, 2016 Pakistan Journal of Ophthalmology Author Affiliation Dr. Mustafa KamalJunejo Instructor Ophthalmology Section of Ophthalmology, Department of Surgery, Aga Khan University, Karachi, Pakistan Dr. Tanveer Anjum Chaudhry Section Head of Ophthalmology Department of Surgery, Aga Khan University Hospital Karachi, Pakistan Role of Author Mustafa Kamal Junejo Data collection, Manuscript writing and Statistics. Tanveer Anjum Chaudhry Data collection. REFERENCES 1. Arai M, Ohzuno I, Zako M. Anterior chamber depth after posterior chamber intraocular lens implantation. 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