EyeWorld India June 2013 Issue

28 EWAP CAtArACt/IOL June 2013 Is extracap still necessary? by Michelle Dalton EyeWorld Contributing Writer With all the technologies available to surgeons, is there still a place for extracap procedures? W hile no one will argue the safety or efficacy of phacoemulsification, the need for surgeons to perform extracapsular cataract extraction today is more controversial. In manual small incision cataract surgery (MSICS) incisions are around 6-7 mm, and in traditional extracapsular cataract extraction (ECCE) incisions are closer to 11 or 12 mm. “The important thing to remember about small incision ECCE is that a properly constructed incision will cause very little astigmatism and often will self-seal,” said Thomas A. Oetting, MD , professor of clinical ophthalmology, University of Iowa, chief of eye service, and deputy director of surgery service, VAMC Iowa City. Dr. Oetting said he’s “very low” on his learning curve with small incision extracap (of the 10,000+ cataract surgeries he’s performed he guessed fewer than 10 had been small incision ECCE), so he sutures his wounds. Jeff Pettey, MD , assistant clinical professor of ophthalmology, Department of Ophthalmology and Visual Sciences, University of Utah, and in practice, John A. Moran Eye Center, Salt Lake City, is an advocate of small incision ECCE simply because surgeons need to have that skill should something go awry with the phaco machine. “It’s nice to be able to convert to a manual procedure, but in the developing world, the sheer volume and cost is so great that having a technique like small incision cataract surgery with comparable outcomes to phaco is imperative,” Dr. Pettey said. In small incision extracap, “there is no ultrasound energy being released inside the eye,” Dr. Oetting said. “Sanduk Ruit, MD, published an amazing study 1 that randomized patients to modern Planned large incision ECCE Source: Thomas A. Oetting, MD phaco or small incision extracap in Nepal, with each group of patients receiving care from experienced surgeons. In this well-constructed study, small incision ECCE clearly was better than phaco in this group of patients with advanced cataract. The post-op vision was a bit better, there were fewer complications, the OR time was about one-half of the phaco procedure, and the cost of the small incision ECCE procedure was less than 1/10 that of the phaco procedure,” Dr. Oetting said. “Based on that alone, shouldn’t everyone be learning small incision extracap?” Dr. Pettey agreed—at John Moran the attending surgeon (Alan Crandall, MD) “could do an intracap, extracap, and everything in between. There’s nothing that will come up in surgery he’s not prepared to handle, but as a resident I learned 100% entirely on phaco,” he said. Between the two procedures, small incision is “superior” to large incision, but residents should be learning all three (including phaco), Dr. Oetting said. “I visited the amazing Aravind Hospital in India, and they teach these procedures so beautifully,” he Ian YEO, MD Senior Consultant, General Cataract and Comprehensive Ophthalmology Service Deputy Medical Director( Education) SNECVice-Chair, Ophthalmology Academic Clinical Program Tel. no. +65-62277255 ian.yeo.y.s@snec.com.sg H aving been trained with extracapsular cataract extraction before migrating to phacoemulsification allows me to have perspective on the use of both types of cataract surgery. In Asia, just like in most parts of the world, the ready availability of phacoemulsification and increased expertise with the technique allows us to perform cataract surgery effectively and efficiently even with very dense cataracts. However, there is significant morbidity (corneal endothelial loss and increased risk of intraocular complications) when managing very dense cataracts. This is where extracapsular cataract extraction techniques still have an important role. The ability to convert from phacoemulsification to extracapsular cataract surgery has helped me in numerous occasions especially when I was starting with my phacoemulsification surgery. A properly done extracapsular surgery when indicated (e.g. lost rhexis) will give excellent outcomes when having to convert. Corneal wound construction and suturing skills are integral parts of the extracapsular surgery procedure and key to the success of the technique. These skills learned will also help prepare residents for other forms of retinal microsurgery like in corneal or glaucoma surgery. The challenge today is finding enough suitable patients to allow residents to be trained in extracapsular techniques. Increasingly, patients will demand “newer” techniques due to shorter recovery time and more comfort. Sadly, even in Singapore we are seeing the progressive demise of this once revolutionary technique that remains effective and very cost effective. Editors’ note: Dr. Yeo has no financial interests related to his comments. Views from Asia-Pacific