Microsoft Word - Tariq khan 32 Original Article Visual Outcome and Complications of Manual Sutureless Small Incision Cataract Surgery Muhammad Tariq Khan, Sanaullah Jan, Zakir Hussain, Samina Karim, Muhammad Kamran Khalid, Lal Mohammad Pak J Ophthalmol 2010, Vol. 26 No.1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations … ……………………… Correspondence to: Muhammad Tariq Khan 2-Lakhkar Khan Road University Town Peshawar Received for publication May’ 2009 … ……………………… Purpose: To determine the surgically induced astigmatism and complications of manual sutureless small incision cataract surgery (SICS). Material and Methods: The study was conducted in the Department of Ophthalmology, Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Postgraduate Medical Institute (PGMI), Hayatabad Medical Complex (HMC), Peshawar. In this study evaluation of 150 eyes of 134 patients were included in this study. Cataract surgery was performed in all cases by manual sutureless small incision technique. Patients were thoroughly examined and visual acuity & keratometry were recorded pre-operatively and at follow-up visits. The type and amount of astigmatism were calculated from the keratometry readings. Any complications found during surgery or on follow up visits were also recorded. Results: Final best-corrected visual acuity 6-months post-operatively was ≥ 6/18 in 86.8 % of cases as compared to pre-operative VA (≤ 6/60) in 82% of eyes. Astigmatism was noted to be significant or high in 50 % cases. This study proved that course of time has no significant effect on the final amount of post- op astigmatism in eyes operated by manual SICS. Other complications included hyphema noted in 17 (11.3 %) cases, posterior capsule rupture in 5 (3.3 %) cases, endophthalmitis in 2 cases (1.3 %) at 1st post-op day. Third case, who had developed panophthalmitis presented 1-week post-operatively and affected eye was eventually eviscerated. Conclusions: Manual SICS is a safe and effective procedure with rapid visual rehabilitation. The amount of post-operative astigmatism was high in significant number of cases. The final best-corrected visual outcome was good in most of cases. ccording to WHO estimates of global data on blindness, there are an estimated 38 million blind people worldwide, and a further 110 million with low vision who are at risk of becoming blind. Age-related cataract accounts for nearly half of these blind individuals, and is particularly common in developing countries. WHO reports that there is a backlog of cataract of approximately 15.8 million people with an annual increase of over 2 million newly cataract-blind patients1. Blindness rate in Pakistan is unacceptably high (1.78% of the total population), of which 66.7% are blind because of cataract2. Phacoemulsification is now standard technique routinely performed for cataract extraction in developed countries, as it offers early visual rehabilitation and better un-aided visual acuity than the conventional sutured planned extracapsular cataract extraction (ECCE). Owing to the expenses of equipment and consumables, and the high proportion of eyes with densely mature cataracts, phaco- A 33 emulsification has had a limited role in many developing countries including Pakistan. In order to obtain the advantages of a self-sealing sutureless incision with least surgically induced astigmatism at a low cost, developing world ophthalmologists have adopted alternatives to phaco-emulsification. Manual sutureless small incision cataract surgery (SICS) has been proved to be an equally effective and a highly cost-effective alternative to instrumental phaco with a low complications rate3,4. It is generally noticed that the incidence of postoperative astigmatism is more when cataract extraction is done through the corneal incision and the more anterior the incision the greater the induced astigmatism5. Different studies from local and international studies had reported that manual sutureless small incision cataract surgery is an encouraging technique and that good visual results can be obtained in over 85% of cases with some associated complications like post-operative astigmatism, per-operative hyphema and irido-dialysis, etc6,7,8,9. The purpose of this study was to produce local evidence regarding visual outcome, surgically induced astigmatism and technique-related complications of manual sutureless SICS. MATERIAL AND METHODS This study included 134 patients (150 eyes) at Khyber Institute of Ophthalmic Medical Sciences (KIOMS), PGMI, Hayatabad Medical Complex, Peshawar, Pakistan. All surgeries included in the study, were performed by the principal author. Pre-operative examination like visual aquity, detailed slit lamp examination, IOP check, a scan and keratometry was carried out for all cases. Type of cataract was recorded on the basis of morphology as immature, mature, hypermature (morgagnian), intumescent, and large nucleus. Keratometric findings of all the eyes were recorded pre-operatively and then at all follow-up visits. Keratometric findings were noted in diopters and the axis was mentioned. The type and amount of astigmatism was calculated from keratometry findings pre-operatively and at all follow-up visits. On each follow-up visit, un-aided visual acuity (UAVA), best- corrected visual acuity (BCVA), significant signs (like A/C reaction, corneal striate, wound deformity, hyphema, etc), and any significant symptoms (like eye pain, double vision, FB sensation, etc) were recorded. Astigmatism was recorded as negative cylinder values. Astigmatism was graded and classified according to Holmström’s gradation as, No astigmatism, when it was < 0.25 D Non-significant, when it was ≥ 0.25 D but <1.00 D Significant, when it was ≥ 1.00 D but < 2.00 D High, when it was ≥ 2.00 D The axes of astigmatism were divided into three classes,“With the rule” (minus cylinder at 180o ±15o ), “Against the rule” (minus cylinder at 90o ±15o ) and “Oblique” (minus cylinder at 16 – 74o & 106 – 164o). All the surgeries were performed within either micro-surgical training center’s operation theatre or within the main operation theatre of the Khyber Institute of Ophthalmic Medical Sciences. The eye to be operated would properly be dilated by putting mydriatic drops. Mixed peri-bulbar and retro-bulbar anesthesia was given by injecting mixture of Lignocaine and Bupivacaine at two different sites superiorly and inferiorly. The eye and peri-ocular skin would properly disinfected by painting with povidone-iodine solution. After proper draping, surgeon would approach from superior or temporal side, depending upon the keratometry readings. After conjunctival section, gentle cautry was done to stop any bleed. Any of the four types of scleral incision (smile, straight, frown, inverted V shaped ) was given at a distance of about 2 mm from the limbus, with a number 15 blade. The external width of the incision was 6-8 mm according to the expected size of the nucleus. Sclero-corneal tunnel was made with a crescent knife and entry into the anterior chamber with a 3.2 mm keratome. The internal opening of the incision was wider, so as to facilitate the nucleus delivery. Before entering into the AC, a side port was made at the limbus, at right angle to the plane of approach with the same 3.2 mm keratome. Anterior chamber was filled with visco-elastic substance by injecting it through the side port. Anterior capsulotomy was done with the help of a self-made cystitome and a capsular forcep. Hydro-maneuvers were performed in almost all cases and nucleus was delivered either by hydro-expression or by visco- expression. Cortical matter was then washed out with Simcoe’s cannula and rigid, single-piece poly methyl methacrylate (PMMA) IOL was implanted within the bag or in the cilliary sulcus. Three step scleral wound was then checked for its self sealing character and conjunctiva approximated by closing with gentle 34 cautry. Visco-elastic material was washed out through the side port, and anti-septic dressing was done. Cases were examined at the first post-operative day, 1-week post-op, 6-weeks post-op, and 6-months post-operatively with a slit-lamp and/ or direct/ indirect ophthalmoscope for any significant sign. Z- test (Normal test) and Chi-squared test were applied to the data. In order to see the stabilization of refractive status in the operated eyes, Chi-squared test was applied in testing the hypothesis for time-elapse after surgery and BCVA. SPSS (Statistical Package for Social Sciences) version 8.0 was used in data analysis and graphs formation. RESULTS All 134 patients were divided into three categories according to age. 40 (29.9%) patients were found to fit in category-I (age 40 to 59 years), 81 (60.4%) patients in category-II (age 60 to 79 years), and 13 (9.7%) patients in category-III (age 80 years and above). The mean age of all the patients was found to be 67.18 years. Out of all 134 patients, 77 (57.5%) were males and 57 (42.5%) were females. Out of 150 eyes operated, 82 (54.7%) were right eyes and 68 (45.3%) were left eyes. Site of incision was superior in 57 (38.0%) cases, while in 93 (62.0%) cases, temporal incision was given. Type of incision given in 13 (8.7%) cases was smile, in 41 (27.3%) cases was straight, in 43 (28.7%) cases was frown and in 53 (35.3%) cases, inverted V shapedv (chevron) type of incision was given. Minor intra-operative complications were not documented. Amongst the note-worthy per-operative complications, 23 (15.3%) cases bled from the tunnel causing intra-operative hyphema was noted. These cases were only let to leave operation theatre, when the bleeding had stopped. In 6 (4.0%) cases, some degree of irido-dialysis occurred, none of them to the extent to need repair. In 5 (3.3%) cases, posterior capsule (PC) got ruptured. The astigmatism, calculated from pre-operative keratometry findings was found to be with-the-rule (WTR) in 73 (48.7%) eyes, against-the-rule (ATR) in 27 (18.0%) eyes, and oblique in 32 (21.3%) eyes. No astigmatism was found in 18 (12.0%) eyes pre- operatively. Type of astigmatism preoperatively and on every follow up visit is shown in Table I. Details regarding amount of astigmatism with different type of astigmatism is shown in (Table 2). It is worth to note that during follow up visits, significant no of patients were lost. On 1st post- operative day, all 150 eyes were examined but at 1 week post-operative visit 114 (70%) eyes of 107 (79.9%) were examined, at 6 weeks, post-operatively, 98 (65.39%) eyes of 91 (67.9%) patients were available for assessment and on final visit (6 months post- operatively) only 68 (45.3%) eyes of 64 (47.8%) patients showed for follow up. Regarding complications, 17 (11.3%) eyes were found having hyphema at the 1st post-op follow-up examination. Hyphema resolved in 11 (7.3%) cases in one week and in all cases 6-week post-operatively. Post-operative endophthalmitis was diagnosed in 2 (1.3%) cases on 1st post-op day, which were successfully treated. Another one case, presented 1- week post-operatively with panophthalmitis. This eye had to be eventually eviscerated. Corneal complications (like significant corneal edema and striate keratopathy) were noted in 19 (12.7%) patients at 1st post-op day. Most of these cases were cleared up by the 1-week post-op, after topical steroids and antibiotics usage. In 5 (3.33%) cases, intra-ocular pressure (IOP) was found to be more than the upper level of normal (i.e. above 21 mm Hg) on 1st post-op day. 3 (2.0%) of these cases were put on topical IOP lowering drugs for about a week and were properly monitored. None of these cases was having increased IOP, when they presented 1-week post-operatively. During the six months follow-up period, 7 (4.7%) eyes were found having significant posterior capsule opacification (PCO) to the extent that Nd: YAG capsulotomy had to be done to clear the visual axis. One case was diagnosed with cystoid macular edema (CME) at 6-week post-op and yet another with bullous keratopathy at 6-months post-op follow-up visit. Details of complications in the post-operative follow up is given in (Table 3). Un-aided visual acuity (UAVA) both pre-operatively and post-operatively is shown in Table IV while best corrected visual acuity (BCVA) is shown in (Table 4). DISCUSSION In this study, we tried to assess the safety, efficacy in terms of visual recovery and induced astigmatism in eyes undergoing cataract surgery by the technique of manual sutureless small incision cataract surgery. 35 Table I: Types of astigmatism (n=150) Visits No: of eyes examined n (%) WTR* astigmatism n (%) ATR** astigmatism n (%) Oblique Astigmatism n (%) No astigmatism n (%) Pre-op 150 (100) 73 (48.7) 27 (18.0) 32 (21.3) 18 (12.0) 1st day post-op 150 (100) 90 (60.0) 36 (24.0) 15 (10.0) 9 (6.0) 1-week post-op 114 (76.0) 73 (64.0) 22 (19.3) 11 (9.6) 8 (7.0) 6-weeks post-op 98 (65.3) 62 (63.3) 19 (19.4) 8 (8.2) 9 (9.2) 6-months post-op 68 (45.3) 44 (64.7) 14 (20.6) 5 (7.4) 5 (7.4) *WTR -- With-the-rule ,**ATR -- Against-the-rule, Pre-op—Preoperatively, Post-op—Post operatively Table 2: Amount of astigmatism (n=150) Visits No: of eyes n (%) WTR Astig n (%) ATR Astig n (%) Oblique Astig n (%) No Astig n (%) Nonsig- nificant Signifi- cant High Nonsig- nificant Signifi- cant High Nonsig- nificant Signifi- cant High 0.25