“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