Unaided vision after manual suture less small incision cataract surgery (MSICS)

Dr Abdul Munim KhanMBBS MCPS FCPS

Associate Professor & HODOphthalmology

MBBS MC

Introduction:

• Prevalence of blindness in Pakistan is 2.7 %

• In Pakistan cataract is major cause of blindness (51.5%) and also in the world(47.8% or 17.7 million persons)

• Any opacity of crystalline lens of the eye is called cataract

• Treatment is mainly surgery

• Phacoemulsification with foldable intra ocular lens (IOL) is the gold standard

• MSICS, a new surgical technique is gaining popularity as it is cheaper and less technology dependant and gives almost equal visual results as phaco

• This study was done to assess the efficacy of MSICS by recording unaided vision four weeks after operation, in our population

Material and methods:

• This study was done at a local NGO Eye Hospital

• Informed consent was taken from all the patients and permission was taken from the hospital ethics committee for conducting the study.

• 78 consecutive patients who reported for follow up, four weeks after MSICS from 1 Jan - 31 Mar 2012 were selected for the study

• Patients were followed up on first post operative day, then at 2 weeks and finally at four weeks and four weeks the unaided vision was especially recorded

Inclusion and exclusion criteria:

• Patients in whom cataract was the main cause of visual impairment were included in the study.

• Patients having uncontrolled diabetes and hypertension were excluded from the study.

• The data was collected on pre designed proforma and analyzed on SPSS 17

• Scs

Steps Of Surgery

1. Frown Incision 2. Scleral Tunnel 3. Capulorrexhis

4. 5. Manual cracking of nucleus into two 6. Prolapse of heminucleus in AC

7-8. Delivery of heminucleus 9-10. size main wound 5.5 mm

11. IOL 12. Implantation of IOL

13. Dialing of IOL Into the Bag 14. Hydration of side-port

Results:

• Out of total 78 patients, 49 (62.82%) were females and 29 (37.12%) were males.

• Ages ranged from 25-88 years (average 63.65 years)

Pre-operative BCVA (%)

• 6/24-6/60 35 (44.87)

• Less than 6/60 41 (52.56)

Post Operative Unaided Visual Acuity

Uncorrected

vision

Patient

number

percentage

6/6 23 29.4

6/9 26 33.3

6/12 19 24.3

6/18 2 2.5

6/24 4 5.1

6/36 1 1.2

6/60 3 3.8

Less than 6/60 0 0

Astigmatism (SIA)

Pre operative 0.99 Diopters

Post operative 1.11 Diopters

SIA 0.12 Diopters

Results according to WHO standards

Visual Acuity Post-operative

UCVA (%)

Good 6/18-6/6 70 (89.74)

Moderate 6/60 -6/24 10 (12.82)

Poor < 6/60 0 (0)

• The treatment of cataract is cataract extraction

• The main objectives of modern cataract surgery

1. better unaided vision

2. rapid post surgical recovery

3. minimal complications

Discussion

• Two types of cataract surgery are performed worldwide;

• 1. Extra Capsular Cataract Extraction with Intra Ocular Lens (ECCE with IOL)

• 2. Phacoemulsification with foldable IOL

• MSICS, a new surgical technique is gaining popularity as it is cheaper and less technology dependant and gives almost equal visual results as phaco

• various studies show that:

• visual results of Phacoemulsification are better than ECCE (Zawar and Gogate, 2011 )

• visual results of MSICS are better than ECCE.

• (Gilbert et al 2011)(Pershing and Kumar 2007) (Zia, Raza and Ali, 2010)

• MSICS is almost equal to Phacoemulsification and even better than phaco (Ruit et al 2007)

Recommendation of WHO regarding outcome of any cataract surgery

After surgery vision may be Good (6/6-6/18) borderline and poor (<6/60)

Recommendation of WHO

Good uncorrected visual acuity in at least 80% and poor outcome in less than 5% of patients

• In this study, nearly 90% of patients attained good unaided post op vision this is 10% more than the recommendation by WHO.

• Study by Ruit S et al in 2007 in Nepal also achieved similar results .

Excellent unaided vision in MSICS is due to

• Small incision 5.5-7.00 mm as opposed to 10-12 mm in ECCE

• Scleral tunnel leading to self sealing incision requiring no sutures

• Astigmatically neutral location of the main incision

Additional factors in this study

1. good pre operative evaluation

2. accurate biometry

3. construction of an optimal self sealing and almost astigmatically neutral sclera tunnel (SIA only 0.12 Diopters)

4. placement of IOL in the bag and

5. single experienced surgeon (author)

•MSICS may preferred to phaco due the following reasons

1. Almost equal visual results

2. Very high Cost of phaco machine, phaco related consumables and maintenance

3. longer learning curve of Phaco

4. Use of expensive foldable IOLs in Phaco

5. Longer operative time of Phaco

• Hence in developing countries like Pakistan MSICS maybe preferred method to carry out

high volume and relatively cheap cataract surgery

Conclusion:

1. MSICS achieved excellent unaided visual outcome, 90% achieved good unaided vision.

2. It is highly effective in the rehabilitation of cataract patients.

3. Hence it is highly recommended especially for high volume cataract surgery in developing countries like Pakistan.

References1. Jadoon MZ, Dineen B, Bourne RR, Shah SP, Khan MA, Johnson GJ, Gilbert CE,

Khan MD. Prevalence of blindness and visual impairment in Pakistan: the Pakistan National Blindness and Visual Impairment Survey. Invest OphthalmolVis Sci. 2006 Nov;47(11):4749-55.

2. Resnikoff S, Pascolini D, Etya'ale D. et al. Global data on visual impairment in the year 2002. Bull World Health Organ 2004. 82844–851.851.

3. Dineen B, Bourne RR, Jadoon Z, Shah SP, Khan MA, Foster A, Gilbert CE, Khan MD. Causes of blindness and visual impairment in Pakistan. The Pakistan national blindness and visual impairment survey. Pakistan National Eye Survey Study Group. Br J Ophthalmol. 2007 Aug;91(8):1005-10.

4. Sajjad Haider, Arif Hussain, Hans Limburg Cataract blindness in ChakwalDistrict , Pakistan : results of a survey.. Ophthalmic Epidemiology 2003, Vol.10, No.4, pp. 249-258

5. Asoke Garg et al.master’s guide to manual small incision cataract surgery MSICS. 2009; 1STEdition: 3

6. Rajesh Sinha, Prakashchand Agarwal, Chandrashekhar Kumar R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India Small incision cataract surgery: Review of journal abstracts Year:2009 Volume: 57Issue:1Page : 79-82

7. Zawar, S.V., Gogate, P. Safety and efficacy of temporal manual small incision cataract surgery in India. European Journal of Ophthalmology. 2011; 21(6): 748-753

8 Sohail Zia, Ali Raza, S Imtiaz Ali. Comparison of Small Incision Cataract Surgery with Extra Capsular Cataract Extraction.Journal of Rawalpindi Medical College (JRMC); 2010;14(2):84-86

9 Clare E. Gilbert, Selvaraj Sivasubramaniam, Gudlavalleti V.S. Murthy, Raj Maini, Mansur M. Rabiu, Abdullahi U. Imam .Outcome of Cataract Surgery in Nigeria: Visual Acuity, Autorefraction, and Optimal Intraocular Lens Powers—Results from the Nigeria National Ophthalmology. 2011; 118(4): 719

10 Suzann Pershing, Abha Kumar. Phacoemulsification versus extracapsularcataract extraction: where do we stand? : Current Opinion in Ophthalmology. 2011; 22(1): 37

11 Ruit, S. et al. Am J Ophthalmol2007; 143(1):32–38

12 Editorial WHO Guidelines and Recommendations for the Post-operative Outcome of Cataract Surgery with IOL. Community Eye Health Vol 16 No. 48 2003 pp49-51 l

13 Gogate et al. Extracapsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: a randomised controlled trial.Br J Ophthalmol. 2003 June; 87(6): 667–672.

14 Shen, L.-X., Cai, J.-L., Huang, C.-L., Guo, J. Comparison of the efficacy of extracapsular cataract extraction combined with intraocular lens implantation by two kinds of converse frown and trapezoidal scleral small incision. International Journal of Ophthalmology. 2010; 10(6): 1061-1063

Thank You