EyeWorld Asia-Pacific September 2011 Issue

37 EW CATARACT/IOL September 2011 Dealing with an unfortunately common problem in the region W hite cataracts are very common in the developing world, according to Rengaraj Venkatesh, MD, Aravind Eye Hospital, Pondicherry, India. Unfortunately, in such cases, while it’s still possible to do phacoemulsification— the most advanced technique available—there are many related complications, especially among patients of surgeons who are less skilled in the procedure, he said. “Because manual SICS [small- incision cataract surgery] is significantly faster, less expensive, and less technology-dependent than phacoemulsification, it may be a more appropriate technique in eyes with mature cataract in the developing world,” Dr. Venkatesh said. Therefore, Dr. Venkatesh and his colleagues conducted a randomized, prospective study to compare the safety and efficacy of phacoemulsification and manual SICS to treat white cataracts in southern India. The researchers randomly assigned consecutive patients with white cataracts to have phacoemulsification or manual SICS by one of three surgeons experienced in both techniques. They compared surgical complications, operative time, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, and surgically induced astigmatism. The researchers reported that 1 day post-op, the uncorrected distance visual acuity (UDVA) was comparable in the two groups (P=0.805), and the manual SICS group had less corneal edema (10.2%) than the phacoemulsification group (18.7%) (P=0.047). The results showed similar uncorrected visual outcomes between the two groups at 6 weeks, Dr. Venkatesh said. Although the phaco group had an edge over the manual SICS group because the incision was smaller, the SICS group also did well, he said. UDVA was 20/60 [6/18] or better in 99 patients (87.6%) in the phacoemulsification group and 96 patients (82.0%) in the manual SICS group (P=0.10), and the corrected distance visual acuity (CDVA) was 20/60 or better in 112 (99.0%) and 115 (98.2%), respectively (P=0.59), the study authors wrote. In addition, the average time it took for surgery was statistically significantly shorter in the manual SICS group (8.8 minutes±3.4 [SD]) than in the phacoemulsification group (12.2±4.6 minutes) (P<0.001), the study authors noted. In terms of complications, posterior capsule rupture occurred in three eyes (2.2%) in the phacoemulsification group and two eyes (1.4%) in the manual SICS group (P=0.681), the study said. The researchers concluded that both techniques achieved excellent visual outcomes with low complication rates. Cracking hard cataracts in the developing world by Enette Ngoei EyeWorld Contributing Editor Mark Packer, MD, clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., USA, said it is remarkable how good the results from SICS in these very difficult cases were. “The results are comparable to phaco in this group a third of the time. The procedure is significantly quicker and the complication rate is the same. Depending on where you draw the line in terms of results, their uncorrected visual acuity is about the same at 6 weeks,” he said. In this case, the researchers drew the line at 20/60, Dr. Packer said, which is a relevant line for people in the developing world. When encountering a cataract like these mature white brunescent cataracts, Dr. Packer said he thinks about doing an extracapsular cataract extraction because the amount of phaco ultrasound energy needed would toast the corneal endothelium, and he would end up having to deal with corneal edema. On the other hand, opening the eye to the size of an extracapsular incision increases the risk of an expulsive choroidal hemorrhage or certainly astigmatism, he said. Dr. Packer said that in this study, while the surgically induced astigmatism was higher in the manual SICS group, it wasn’t off the charts. Dr. Venkatesh said that he and his colleagues strongly feel that in advanced cataract cases, it is better to perform small-incision surgery than phacoemulsification as it is more cost efficient, has fewer complications, and when compared with phacoemulsification, offers equal if not better uncorrected visual acuity at the end of 1 month when the wound heals completely. Small-incision surgery is the most popular technique, whether it is a white cataract or a normal cataract, in the developing world because of the lack of availability of phaco machines, the training needed to perform phaco, and the cost related to daily consumables such as tubing, phaco tips, and foldable IOLs, Dr. Venkatesh said. For most surgeons in the developing world, especially in India, the rest of Asia and Africa, small-incision surgery is the predominant procedure. Dr. Packer said that for surgeons who are considering learning this, there are organizations like the Himalayan Cataract Project that welcome people to come and volunteer for a period of time and learn it for themselves. “I think it’s fascinating to see this in action. There are incredibly fast surgeons, and they make it look like a whole different operation than what we’re used to,” Dr. Packer said. EW Editors’ note: Drs. Packer and Venkatesh have no financial interests related to their comments in this article. Contact information Packer: 541-687-2110, mpacker@finemd.com Venkatesh: venkatesh@pondy.aravind.org