Ординатура / Офтальмология / Английские материалы / The Art of Phacoemulsification_Mehta, Alpar_2001

522 THE ART OF PHACOEMULSIFICATION

that a phaco eye camp would prove costlier. Nothing is further from the truth. Tables 48.1 to 10 show the pertinent data in a small eye camp done consecutively, in the same area 4 months apart. Phaco has proven to be very economical.

In a county like India and for that matter any Third World or underdeveloped country, where there is acute financial stringency, the ability to do more cases for much less is a very important factor.

Table 48.1: Phaco camp at Dhappandar village: Maharashtra

• A controlled study utilizing a minimal team of 3 refractionists, 8 nursing technicians, and a single surgeon.

•Total cases examined preoperative = 1865

•Refraction done on = 845 cases

•Cataracts detected = 122 of which 107 elected for surgery.

•Two surgical days, session 8.00 AM to 5 PM with breakfast, lunch and tea breaks. Most cases (84/107 = 91.3%) under topical.

Advantages of Phaco over ECCE as an Eye Camp Alternative

The greatest advantage of phacoemulsification is the virtually negligible quantities of astigmatism it produces even if a 5.00 mm PC IOL is inserted via a sclerocorneal incision and tunnel. ECCE despite our best efforts has proven infructuous and has, in simple words proven to be inadequate to the task in hand. The other very big advantage is obviously the immediate rehabilitation with virtually negligible postoperative late complications (almost 17% with ECCE). And finally, it is much cheaper to do phaco as compared to ECCE.

Final Analysis

Phaco is literally 10 times cheaper than ECCE.

PROBLEMS OF A PHACO EYE CAMP

•Phaco instrument needs a stable power supply. Fortunately the Honda generators are available nowadays which function well.

•Use of a good stereopticon microscope with adequate depth of field is essential.

•Need of UPS (uninterrupted power supply on all phaco machines and on the A scan units

•Need for a miniflash autoclaves since phaco probes cannot be boiled.

•Well-trained phaco team to permit rapid turn-around of cases.

•Well-trained phaco surgeon with experience in handling hard cataracts and managing complications

HOW GOOD IS INDIA’S ATTEMPT AT CONTROL OF

BLINDNESS FOLLOWING CATARACT SURGERY

•The results from cataract surgery, in being able to achieve adequate vision in eye camps is so poor that one is constrained to say that while cataracts

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Table 48.2: Assessment of cataracts in phaco eye camp

Table 48.4: Surgical complications: phaco eye camp (n = 107)

Table 48.5: Raw costing of a phaco eye camp

are the highest cause of blindness in India, the second highest cause of blindness after cataracts, is surprisingly, cataract surgery.

•The success rates following cataracts surgery range from 30 to 50 percent success. The invariable cause of failure is inadequate visual correction, more often than not, due to excessive quantities of astigmatism.

•The second biggest cause for failure is postoperative complications which were untended primarily, subsequently not noticed, improperly managed, or simply ignored (usually the latter).

Table 48.7: Surgical expenses: phaco vs ECCE

Analysis It would seem obvious from the statistics that the sight restoration rate (Table 48.11) even with as broad a criteria as 6/60 ranges hardly from 28 to 39 percent. In essence virtually 7 out of 10 do not regain useful vision, certainly not anything to be proud about.

POOR OUTCOMES IN CATARACT SURGERY

Analysis of 4168 cataract surgeries meticulously followed showed

•37.8% good outcome—6/18 or better

•45.6% borderline outcome—6/24-6/60

Where are the Answers?

The obvious answer is

•Improve drastically the quality and level of surgery. The results show that it is mandatory.

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Table 48.8: Nonsurgical expenses: phaco vs ECCE

•Prescribe perfect postoperative glasses. The heinous crime of giving standard “plus lens” should be discontinued forthwith if one is not to convert the “cataract blind” to “spectacle blind”.

•Try and decrease astigmatism as far as possible. It will not only permit better postoperative vision but will need to have fewer refractive changes later.

•Achieve a much higher level of accuracy in IOL power calculation . This also means far more accurate keratometry.

•Common sense indicates that it is now time that ECCE gave way to phaco.

The proportion of cataract operations with a visual outcome less than 6/60, by place and type of surgery

Why not Small Incision ECCE Rather than Phaco. Is it a Viable Option?

There has been a strong trend in utilising the small incision techniques like the Blumenthal technique and the sandwich technique, or for splitting the nuclei with various instruments in an effort to do the entire surgery through a 6.00 to 7.00 mm incision.

The methods seem so easy and the results are commented upon at all major meetings as being just short of extraordinary that it is not surprising that there has been a trend to shift from regular ECCE to small incision ECCE.

It would solve the problem of astigmatism, and would, to some extent even sort out the problem of late complication of ECCE and would not, in a good majority even need to be sutured, or if sutured a single mattress suture may prove adequate.

The problems however slowly came to light. Gross endothelial cell decompensation. In an eye camp held in the periphery of Maharashtra where the authorities called its a “phaco style” surgery, the follow-up after 6 months showed almost 18% had hazy vision due to corneal decompensative changes. Obviously, unless the surgeons were superbly trained and used excellent microscopes, as an eye camp surgery, small incision ECCE was a catastrophe. One of us ( KRM) spoke about it at the state conference and labeled it as the “endothelial holocaust“. Its bad to leave astigmatism, but to leave decompensated corneas is criminal.

Endothelial Holocaust

More corneas have been ruined from trying to do an inadequate non-phaco small incision cataract surgery then all the transgressions,till date, combined.

Why the Endothelial Holocaust

• The corneal dome has inadequate space for gymnastics.

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•The perception of depth is often inadequate unless exceptional microscopes are used.

•Multiple entry in and out of the eye will invariably lead to inadvertent corneal touch with grave results.

•A panicky surgeon leads to a lost eye. Nothing panics a surgeon as much as an uncooperative lens in a small incision surgery.

•Subsequent often flat chambers due to traumatized wound entries lead to a

further exacerbation of the problem

Unfortunately it is the occasional surgeon, who tries his hand at small incision ECCE and rather than learn phaco, decides here is a simpler, cheaper way . The only advice one can give him is “Take it easy. If you really want to do small nonphaco techniques, learn from a master or take up Phaco. But please let the cornea survive.” Let us not wage a war against the poor unsuspecting, endothelium Let there be peace.

PHACO VS ECCE EYE CAMP: THE FINAL WORD

Undoubtedly, phaco eye camps are the way to go. The only barrier is the surgeon, as he or she has to be trained in the specialty, and must have the confidence to do so.

Considering the virtually complication free status of phaco surgery, and the cost, literally 10 times cheaper than ECCE with results which are superb as compared to ECCE, one would feel that it is only a question in time when all eye camps, hopefully, and mercifully will be conducted ONLY by the phaco way.

FURTHER READING

1.Mehta KR: Phacoemulsification cataract extraction with foldable IOLS—first 50 cases. All India Ophthl Soc Proc 56-60,1989.

2.Mehta KR: Clear corneal phaco with injectable silicone IOL proc. All India Ophthl Soc Proc (Mumbai) 1995.

3.Mehta KR: Mehta tangential chop (MTC) technique for phacoemulsification. All India Ophthl Soc Proc (Chandigarh) 1996.

4.Mehta KR: Combined astigmatic annular keratotomy and phaco—a corneal topographic analytical techniques. All India Ophthl Soc Proc (Chandigarh) 1996.

5.Mehta KR: Lollipop phaco cleavage—a new technique for hard cataracts. All India Ophthl Soc Proc (Bangalore) 1991.

6.Mehta KR: Phaco with flexible IOL—is it a step forward. All India Ophthl Soc Proc (Bangalore) 1991.

7.Mehta KR: Comparison of centration stability and capsular response to AcrySoft and silicone S130 lenses. All India Ophthl Soc Proc, 1998.

8.Mehta KR: Teaching standards in phacoemulsification—how realistic are they? All India Ophthl Soc Proc, 1998.

9.Mehta KR: Use of intracameral yellow (Kodak Wratten 59 Filter) fibreoptic light source for phacoemulsification in dense corneal opacities prior corneal transplantation. All India Ophthl Soc Proc, 1998.

10.Mehta KR: The tripod posterior chamber flexible acrylic implant—the answer to better stability.APIIA Conference, 1997.

11.Mehta KR: Intralenticular “hubbing” technique for simple eye camp phacoemulsification—a simple technique. APIIA Conference, 1997.

528 THE ART OF PHACOEMULSIFICATION

12.Mehta KR: Astigmatic control using the new curved laminating keratotomy technique. APIIA Conference, 1997.

13.Mehta KR: Newer techniques for eye camp safe phaco techniques. APIIA Conference, 1997.

14.Mehta KR: The tripod posterior chamber foldable acrylic lens. Proc of SAARC Conference, Nepal, 1994.

15.Mehta KR: Phacoemulsification, the “roller-flip” way for suprahard cataracts—it works great. Proc of SAARC Conference, Nepal, 1994.

16.Mehta KR: Management of subincisional cortex in small incision cataract surgery (SICS). Proc of SAARC Conference, Nepal, 1994.

17.Mehta KR: Intralenticular “hubbing” phaco technique for safe phaco. Proc of SAARC Conference, Nepal, 1994.

18.Mehta KR: Methylcellulose induced sterile endophthalmitis following phacoemulsification. Proc of SAARC Conference, Nepal, 1994.

19.Mehta KR: Double intraocular lens implantation for high ametropia and for correction of inadvertant remnant ametropia. Proc of SAARC Conference, Nepal, 1994.

20.Mehta KR: Comparison of scleral vs transiridial corneal suspended vs iridial suturing of PC IOL implants with inadequate capsular support. Proc of SAARC Conference, Nepal, 1994.

21.Mehta KR: The new multiport phaco tip for safer, more effective phacoemulsification, with virtually zero capsular damage. Proc of SAARC Conference, Nepal, 1994.

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