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First Postoperative Day Visual Outcome Following 6 mm Manual Small Incision Cataract Surgery Using Intratunnel Phacofracture Technique

US Ophthalmic Review, 2014;7(1):26–30 DOI: http://doi.org/10.17925/USOR.2014.07.01.26

Abstract:

Object: To study first postoperative day visual outcome following 6 mm manual small incision cataract surgery (MSICS) using intratunnel phacofracture technique. Design: Retrospective design. Setting: Tertiary eye care centre. Participants: A total of 216 patients who underwent MSICS performed by a single surgeon at the JW Global Hospital & Research Centre, Mount Abu, India from April 2012 to March 2013. Cataract patients with any other ocular comorbidity were not included. One hundred and thirty-six cataract patients (72 male/64 female) with a mean age of 59.75 years (range 40–80 years) were included in the study. All surgeries were performed by a single surgeon using the 6 mm MSICS intratunnel phacofracture technique. Outcome measures: The first postoperative uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), and rates and types of complications were recorded. Results: A total of 136 surgeries were performed using the 6 mm MSICS intratunnel phacofracture technique. All the surgeries were performed by a single experienced surgeon. The mean UCVA and mean BCVA at first postoperative day were 0.367 (Snellen equivalent 20/46) and 0.226 (Snellen equivalent 20/33) log MAR units, respectively. No serious peri- and postoperative complications were encountered. Conclusions: The 6 mm MSICS is a safe, fast, and low-cost cataract extraction technique. It is an effective alternate to costly phacoemulsification.
Keywords: MSICS, intratunnel, phacofracture, SICS, cataract
Disclosure: Sudhir Singh, MS, has no conflicts of interest to declare.
Received: October 29, 2013 Accepted March 14, 2014
Correspondence: Sudhir Singh, MS, Senior Consultant and Head, Department of Ophthalmology, JW Global Hospital & Research Centre, Mount Abu, Rajasthan 307501, India. E: drsudhirsingh@gmail.com
An erratum to this article can be found below.

Compliance with Ethical Guidance: Informed consent was taken from all patients.

Cataract is the leading cause of avoidable blindness in the world.1 Manual small incision cataract surgery (MSICS) and phacoemulsification (phaco) are the most popular methods of cataract extraction today. MSICS is significantly faster, less expensive, and less technology-dependent than phaco, and has been extensively practiced in developing countries such as India. It has similar advantages of phaco in the rehabilitation of the cataract blind. It is also easier for a surgeon trained in extracapsular cataract extraction (ECCE) surgery to master MSICS than phaco. There is no dependence on the phaco machine, and the learning curve is less steep than that of phaco. MSICS was propagated for high-quality, high-volume cataract surgery at the Aravind Eye Hospital, India2,3 and in Nepal.4

The most commonly practiced MSICS techniques are Blumenthal, viscoexpression, irrigating wire vectis, and fish hook needle. These techniques require a 7 to 9 mm large incision, which leads to more astigmatism. Therefore, if the nucleus is managed to be removed through a sub- 6 mm incision at the appropriate site it would result in approximately the same astigmatism as 3.2 mm phaco.5–8 Using our technique, intratunnel phacofracture, all type cataracts can be managed through a sub-6 mm incision. Hence results are similar to phaco. To the best of our knowledge, this is the first study to study postoperative day visual outcome following 6 mm MSICS using the intratunnel phacofracture method of nucleus delivery.

Review of Literature
A common feature of the MSICS techniques reviewed in the literature is that the nucleus is prolapsed into the anterior chamber (AC). The nucleus may then be removed by any of the following techniques:
  • Nucleus delivery using an irrigating vectis2,3,9,10 or a curved cystitome—the fish hook.4
  • Using two instruments to sandwich the nucleus between them.11–13
  • Bisecting the nucleus into two using two instruments: one as the ‘cutter;’ the other, usually a vectis, as the board.11,14,15
  • Using a snare similar to the tonsillar snare.11
  • Dividing the nucleus into three parts (trisection) using a triangular instrument and a vectis.16
  • Using an AC maintainer and a Sheet’s glide (the Blumenthal technique).11,17
  • Viscoexpression of the nucleus.
  • Intratunnel phacofracture technique (our technique).
Material and Methods
We examined the records of 216 patients who underwent MSICS performed by a single experienced surgeon (SS) at the JW Global Hospital & Research Centre, Mount Abu, India from April 2012 to March 2013. Informed consent was taken from all patients. We included all cases with immature senile cataracts (IMSC), mature senile cataracts (MSC), hypermature senile cataracts (HMSC), posterior subcapsular cataract (PSC), posterior polar cataracts (PPC), and nuclear cataracts. Cataracts patients with any other ocular comorbidity were not included One hundred and thirty-six cataract patients (72 male/64 female) with a mean age of 59.75 years (range 40–80 years) were included in the study. Cataracts patients with good fixation and without any other ocular comorbidity were included. A full preoperative ophthalmic examination was performed. Preoperative data collection for each eye included the patient’s age and gender, preoperative visual acuity (VA) (uncorrected and best corrected VA [UCVA and BCVA]) and details of slit-lamp examination. Intraocular pressure was recorded by Sctiøtz tonometry in all cases. The posterior pole was examined with slit-lamp biomicroscopy and indirect ophthalmoscopy. Axial length measurements and keratometry recordings were taken and Sanders- Retzlaff-Kraff (SRK)-II formula was used to calculate the intraocular lens (IOL) power required. First-day postoperative vision was assessed by unaided VA and pin hole (PH) VA.

Surgical Technique
Six mm Manual Small Incision Cataract Surgery with Intratunnel Phacofracture Technique
All surgeries were performed under peribulbar/topical anesthesia by a SS. A 4/0 silk bridle suture was placed beneath the tendon of the superior rectus muscle. A superotemporal quadrant for the right eye and a superonasal quadrant for the left eye was chosen if K1 and K2 difference was equal or less than 1.0 diopter (D). If the K1 and K2 difference was more than 1.0 D then the incision was made on a steeper axis. A fornix-based conjunctival flap at the limbus with a chord length of approximately 6.5 mm was made. After careful dissection of the Tenon’s capsule, light cautery was applied. A 6 mm scleral frown incision, 1.5 mm from the limbus, was made with a No. 15 Bard Parker blade (see Figure 1). A funnel-shaped sclerocorneal pocket incision was created with a steel crescent knife. One side port was made 90° apart on either side of the scleral tunnel with a 15° knife temporally in right eye and nasally in the left eye. With a 2.8 mm keratome, the AC was entered 1.5 mm into the clear cornea. The AC is entered with 1.5 mm in clear cornea with help of 3.2 mm keratotome (see Figure 2).

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Keywords: MSICS, intratunnel, phacofracture, SICS, cataract
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