EyeWorld Asia-Pacific December 2012 Issue

30 EWAP CATARACT/IOL December 2012 Post-op rounds in Namibia. Dr. Colvard serves as volunteer surgeon with SEE International. Source: Mike Colvard, MD ECCE in developing countries by Faith A. Hayden The “outdated” procedure still has a place in certain parts of the world W ith the advancement of phacoemulsification techniques, extracapsular cataract extraction (ECCE) may seem like an outdated procedure to many ophthalmologists. In fact, young ophthalmologists may not be familiar with ECCE at all, having little experience performing the technique in the U.S. Despite the advancements in modern cataract surgery, though, ECCE still has a place. Not only can it be used as a fallback technique should phaco go awry, but surgeons like Mike Colvard, MD , clinical professor of ophthalmology, University of Southern California School of Medicine, Calif., USA, feel it’s the procedure of choice for cataract surgery in developing countries. Dr. Colvard has been volunteering in Africa for more than 20 years as a surgeon with SEE International and believes ECCE is a safer, more practical procedure in underdeveloped settings. Here’s why. EyeWorld : Why do you think that ECCE still has a place in ophthalmic surgery? Dr. Colvard: Advanced cataracts are the most common cause of blindness in underdeveloped countries. Patients in these countries often present with extremely dense hypermature cataracts. These kinds of cases, as we all know, are also often associated with compromised zonules and tissue thin capsules. Frequently the entire capsular bag is filled with rock hard nuclear material. These are long, difficult phaco cases in the best of circumstances that often require expensive ancillary devices such as dispersive OVDs, capsular expansion rings, and/or capsular support hooks. And even with all this in the best of hands, the risk of capsular tears and retained nuclear material is relatively high. These are the kinds of cases we see only occasionally in private practice in the U.S. So we take the extra time, we use everything in the surgery center to make things safer, and if we do have a complication with loss of nuclear material in the vitreous, our exquisitely skilled vitreoretinal surgeons are around to save the day. In underdeveloped countries, virtually every case you face is an extraordinarily dense cataract. ECCE is a better modality in this setting because patient loads are huge, and this procedure is faster, far less expensive, and safer for these kinds of cases, where trained vitreoretinal surgeons are seldom available. David F. Chang, MD, in the 2009 ASCRS Binkhorst Lecture, titled “The Greatest Challenge in Cataract Surgery Needed: 5 minute, $15 Cure for Blindness,” did a marvelous job of explaining why ECCE is still a vitally important procedure in many areas of the world. EyeWorld: You presented at the 2012 ASCRS Film Festival a new technique for performing ECCE. Why do you think that surgeons need a better way of doing an old procedure? Dr. Colvard: One of the chief reservations that most younger surgeons have in volunteering internationally is that they know there is a good chance they will have to perform ECCE—a procedure with which many surgeons have very little experience. While working for years as a volunteer surgeon for SEE International, I developed a simple technique that I believe can allow any well-trained phaco surgeon to perform ECCE with speed and safety. It utilizes variants of maneuvers that phaco surgeons already know how to perform, and it can be learned easily by an experienced phaco surgeon by just watching our video describing the procedure titled, “ECCE for the Phaco Surgeon: The Slip and Slide Maneuver.” My goal in describing this technique is to help younger surgeons to feel comfortable performing ECCE and in that way encourage them to volunteer their skills internationally. EyeWorld: How is your ECCE technique different from the traditional ECCE procedure? Dr. Colvard: The older standard ECCE technique traditionally taught in the U.S. is very difficult to perform without a lot of practice. It involves applying external pressure to the globe opposite the incision in an effort to prolapse the nucleus into the anterior chamber and out of the incision. The “slip and slide maneuver” for ECCE is much safer and more easily reproducible. It simply involves tipping an edge of the nucleus into the anterior chamber, slipping some OVD under the nuclear plate, and then sliding the nucleus into the anterior chamber and out of the eye. This technique protects the capsule and places virtually no pressure on the zonules. Once the nucleus is sitting safely in the anterior chamber, continued on page 34