EyeWorld India March 2017 Issue

40 EWAP CATARACT/IOL March 2017 scale, retrospective, consecutive case series of office-based cataract surgery in the U.S. found that 0.1% of surgery in more than 21,000 eyes was manual ECCE. 4 “There is a learning curve to MSICS, probably equal to that of phaco,” Dr. Fry said. “Possibly surgeons new in practice could get this experience on mission trips, as on many of these, phaco is not available, and even if it were, the dense cataracts seen on mission trips are better handled by MSICS.” Gerald Keener, MD , Community Eye Care of Indiana, Indianapolis, who in the late 1970s created his own manual small incision cataract surgery technique that removed a split nucleus through a 6.5-mm wound, still thinks there is a place for learning a modified small incision extracapsular technique, despite the prevalence of phaco. “There are times when you get in trouble during a cataract extraction and you have to enlarge the wound, and you don’t want to enlarge it to 11 mm. It’s good to know how to get the nucleus of an eye without hugely enlarging the wound,” he said, adding that there are often courses taught on manual small incision cataract surgery at some of the major ophthalmic meetings. There are also cases where a conversion from phacoemulsification might be needed after it was started. A retrospective study of 540 eyes from a center in New Delhi, India, published in 1998, found that a conversion from phaco to ECCE was needed in 22 eyes (3.7% of cases). 5 Reasons included pupillary miosis, posterior capsule rupture, and long phaco time due to a hard cataract. “Optimal preoperative preparation and prompt recognition of complications during phacoemulsification can lead to timely conversion to ECCE to achieve good visual outcome,” Dada et al. wrote. Dr. de la O said he usually has two surgical tables ready: one with a phaco machine and another with equipment ready for MSICS. “I do MSICS while the nurse prepares the phaco and vice versa,” he said, adding that colleagues who conduct follow-up appointments with patients cannot tell if the procedure was phaco or MSICS. “The results in visual acuity are the same, and it’s hard to see the difference on the tunnel scar with the slit lamp weeks later as I perform a sclerocorneal incision covered by healthy conjunctiva on both cases,” he said. But you don’t have to wait for a difficult case to choose to perform MSICS, Dr. de la O said. “You could use it on almost any case,” he said. “I have perfected the technique to the point that I feel comfortable using any type of IOL, including foldables— the preference—under topical anesthesia, [without] cautery and [without a] conjunctival flap. … I’ve even done it combining MIGS for glaucoma.” EWAP References 1. Tabin G, et al. Cataract surgery for the developing world. Curr Opin Ophthalmol . 2008;19:55–9. 2. Fry LL, et al. Clinical Practice in Small Incision Cataract Surgery. 2005. 3. Chen CK, et al. A survey of the current role of manual extracapsular cataract extraction. J Cataract Refract Surg . 2010;36:692–3. 4. Ianchulev T, et al. Office-based cataract surgery: Population health outcomes study of more than 21,000 cases in the United States. Ophthalmology. 2016;123:723–8. 5. Dada T, et al. Conversion from phacoemulsification to extracapsular cataract extraction: Incidence, risk factors, and visual outcome. J Cataract Refract Surg . 1998;24:1521–4. Editors’ note: Drs. de la O, Fry, and Keener have no financial interests related to their comments. Contact information de la O: drdelao@prodigy.net.mx Fry: LuFry@fryeye.com Keener: desserts83@yahoo.com for 2 weeks or more after surgery (16%) could increase antibiotic resistance of organisms on the eyelid, which could pose a problem should the second eye be operated on within a short time frame. David F. Chang, MD , Los Altos, California, shared his thoughts about the survey results, focusing on intracameral antibiotic prophylaxis. He noted that the survey was initiated just prior to ASCRS and the American Society of Retina Specialists issuing a clinical alert on hemorrhagic occlusive retinal vasculitis (HORV), which was reported in 36 eyes of 23 patients who had received intraocular vancomycin. As such, Dr. Chang said he would expect that intracameral vancomycin use has dropped since that time. Among other observations, Dr. Chang noted the continued drop in intraocular antibiotics being administered through the irrigating bottle. Prior ASCRS surveys showed that of those surgeons employing intraocular antibiotic prophylaxis, 48% used the irrigating bottle in 2007 compared to only 16% in 2014, and 18% in the current survey. Francis Mah, MD , Scripps Clinic, La Jolla, California, said the results of the survey, overall, were what he would have expected, but he was “pleasantly surprised” to see a larger number of respondents using intracameral antibiotics. “I was happy that the medical literature has swayed a lot of people into intracamerals. I thought it would have been a lower number,” he said. Dr. Henderson said based on these numbers, “intracameral antibiotics appear to be becoming the standard of care in the U.S.” Dr. Shorstein said the uptick of this practice “points out the need to continue pursuit of an FDA- approved drug.” The Research Council is designing a trial that “will definitively show the benefit of antibiotic prophylaxis, and we’re looking at both topical vehicle delivery systems and intraocular,” Dr. Rhee said. Dr. Mah thinks this is an important issue to research as well. “There is not in the United States an FDA-approved, commercially available medication, regardless of if it’s drops or intracameral, that’s approved for prophylaxis of endophthalmitis or post-cataract surgery infections,” Dr. Mah said. “I think U.S. surgeons deserve a medication or at least some proof to support the use of these medications.” EWAP References 1. Chang DF, et al. Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey. J Cataract Refract Surg . 2007;33:1801–5. 2. Chang DF, et al. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey. J Cataract Refract Surg . 2015;41:1300–5. Editors’ note: Dr. Mah has financial interests with Bausch + Lomb (Bridgewater, New Jersey), Alcon (Fort Worth, Texas), and Allergan (Dublin, Ireland). Drs. Chang, Henderson, Rhee, and Shorstein have no financial interests related to their comments. Contact information Chang : dceye@earthlink.net Henderson : bahenderson@eyeboston.com Mah : Mah.Francis@scrippshealth.org Rhee : dougrhee@aol.com Shorstein : nshorstein@eyeonsight.com Experts discuss - from page 37 MSICS - from page 39