EyeWorld India June 2013 Issue

29 EWAP CAtArACt/IOL June 2013 Views from Asia-Pacific Pannet PANGPUTHIPONG, MD Director, Mettapracharak Hospital and Eye Institute Tambon Raiking, Ampur Sampran, Nakornpathom Province, Thailand 73210 Tel. no. 6681-9118134 Fax no. 6634-321243 pannetp@hotmail.com D ifferent techniques require different skills and each technique has its own pros and cons. I believe that every phaco surgeon should have some ICCE and ECCE skills to manage phaco complications or to plan for ECCE in difficult cases. We still have black or white cataracts in Thailand so residents are trained with ECCE, small incision ECCE (SICS) and phacoemulsification. The Thai government pays a fixed amount of US$240 for the surgery plus US$100 for a foldable IOL or US$35 for a rigid PMMA IOL. By performing SICS, hospitals can save some money for other necessities while final visual outcome remains comparable to phaco. Phacoemulsification is now 80% of all cataract surgeries. Editors’ note: Dr. Pangputhipong has no financial interests related to his comments. Johan A. HUTAURUK, MD Director, Jakarta Eye Center Jl. Cik Ditiro 46, Menteng, Jakarta 10310 Indonesia Tel. no. +62-21-2922-1000 Fax no. +62-21-390-4601 johan.hutauruk@jakarta-eye-center.com I s extracap still necessary? I have no doubt about answering the question with “yes”. The objective of cataract surgery is to remove the cloudy lens and replace it with an artificial intraocular lens, so to perform extracap for a cataract patient is “doing the right thing”. In good hands, the outcomes of ECCE are comparable with phaco surgery as reported by Ruit et al. We all agree that smaller incisions will be more consistent for less induced astigmatism and cataract removal with phacoemulsification is “doing the thing right”, because even if ECCE could give similar visual outcomes, at least cosmetically, the eye looks better right after phaco surgery. We teach our residents at the University of Indonesia to perform ECCE in at least 20 cases before they start to learn phaco. The main reason for this approach is that we need to teach them to perform safe surgery. In our population, one out of five cataract patients come with brunescent cataract, which makes phaco not a good option for a beginner. Murphy’s law: If anything can go wrong, it will. What would you do if during surgery your phaco machines suddenly stop? Dealing with a black cataract so dense that the phaco seems simply not to work? Intraoperative zonulysis? Posterior capsule breaks while the nucleus is still there? Certainly ECCE still has a place as an escape button to overcome these situations. I observe my residents in their learning curve in doing cataract surgery, and the worst case scenario for ECCE is a broken capsule and leaving the patient aphakic, which is not too difficult to fix later on with secondary IOL implantation. On the other hand, if something goes wrong with phacoemulsification, I have seen lots of complications: nucleus drops, bullous keratopathy, and corneal wound burns, and those complications are more devastating both for patients and surgeons. Massive suprachoroidal hemorrhage, although very rare, this heart-breaking complication occurred once in my career as an ophthalmologist and it happened during ECCE. Theoretically, phacoemulsification with closed system will be safer than ECCE in avoiding this complication. Developed countries may have a different situation, with lack of cases suitable for ECCE because most of their patients consult with early cataract. But in my opinion, expert phaco surgeons will know and be capable of ECCE even from watching videos, so teaching residents to perform ECCE with videos and animal wetlabs is still necessary to give them modalities to handle all kinds of cataract. Editors’ note: Dr. Hutauruk has no financial interests related to his comments. said. “They start with limbus-based large incision extracap, then move to small incision extracap, then move to phaco. The mindset there is extracap is easier. My feeling is that phaco is easier, but I’m biased by having learned that technique first.” It’s rare when an ECCE is a planned surgery here in the U.S., both said. Very dense cataracts are probably the leading reason to plan an extracap surgery, Dr. Oetting said. “Phaco is clearly considered to be the standard of care in the U.S., which has made it hard for me to perform ECCE just for the purpose of training. However, for dense cataracts especially the small incision ECCE should be considered a viable option.” Common procedure outside the U.S. Outside the U.S., however, the mindset is much different, Dr. Pettey said. When he finished his residency about 2.5 years ago, he did so without ever seeing or performing an extracap. He purposely chose an international fellowship to gain experience with small incision extracap and has every intention of ensuring the program at John Moran will emphasize the importance of the procedure when he takes over as residency program director this July. “It’s important to teach these techniques; it’s just a matter of finding enough really dense cataracts that warrant doing small incision cataract surgery,” he said. “I think using internet video and other course work, an experienced surgeon can safely learn the small incision ECCE technique,” Dr. Oetting said. For those interested in donating time to mission work “especially in areas where cost is going to be a big concern, they need to learn the procedure. For a dense cataract and areas where you can’t spend $500 on just equipment for the cataract, surgeons need to learn small incision ECCE.” Unfortunately, Dr. Pettey said there just isn’t the volume of cases that justify doing small incision ECCE to train residents well enough to have them perform on their own; “they really need to get their experience overseas. I think this is the only avenue to truly learn how to do this type of surgery flawlessly.” Dr. Oetting cited Bonnie Henderson, MD’s recent paper outlining the current state of teaching ECCE techniques in training programs. 2 Ayman Naseri, MD, University of California, San Francisco, in a recent study found no difference in complications when residents started surgical training with extracap instead of phaco. 3 continued on page 31