Cataract surgery in developing countries

Endothelial cells and central corneal thickness after modified sutureless manual small-incision cataract surgery

PURPOSE

Manual small-incision cataract surgery (MSICS) is a viable method for cataract surgery around the world. We evaluated the impact of a modification of MSICS, in which an anterior chamber maintainer is used throughout the surgery with the addition of ocular viscoelastic device prior to nucleus removal (M-MSICS), on the corneal endothelium.


METHODS

This prospective study comprised patients randomly assigned for cataract surgery who underwent M-MSICS. Patients underwent corneal endothelial counts by a noncontact specular microscopy in the center and at 12 and 6 o'clock position as well as central corneal pachymetry (CCT) preoperatively, and at 1 week and 1 and 3 months postoperatively. 


RESULTS

Twenty-one eyes were included, 16 of which completed the entire follow-up. There was a statistically significant difference in endothelial cell loss at the center of the cornea at 1 week postoperatively (p = 0.003). However, there was no significant difference in endothelial cell measurements between preoperative and other postoperative timepoints at the center of the cornea. In addition, no significant difference was found in the 12 and 6 o'clock measurements at all timepoints. There was a mild but statistically significant increase in CCT at the center of the cornea at 1-week and 1-month postoperative measurements as compared to preoperative measurement (p<0.05). By postoperative month 3, CCT had returned to baseline level. 


CONCLUSIONS

Modified MSICS offers a viable enhancement of MSICS, with mild and transient impact on the corneal endothelial cell density and corneal pachymetry.

Elimination of avoidable blindness due to cataract: where do we prioritize and how should we monitor this decade?

Background:

In the final push toward the elimination of avoidable blindness, cataract occupies a position of eminence for the success of the Right to Sight initiative.

Aims:

Review existing situation and assess what monitoring indicators may be useful to chart progress towards attaining the goals of Vision 2020.

Settings and Design:

Review of published papers from low and middle income countries since 2000.

Materials and Methods:

Published population-based data on prevalence of cataract blindness/visual impairment were accessed and prevalence of cataract blindness/visual impairment computed, where not reported. Data on prevalence of cataract blindness, cataract surgical coverage at different visual acuity cut offs, surgical outcomes, and prevalence of cataract surgery were analyzed. Scatter plots were used to look at relationships of some variables, with Human Development Index (HDI) rank. Available data on Cataract Surgical Rate (CSR) was plotted against prevalence of cataract surgery reported from surveys.

Results:

Worse HDI Ranks were associated with higher prevalence of cataract blindness. Most studies showed that a significant proportion of the blind were covered by surgery, while a fifth showed that a significant proportion, were operated before they went blind. A good visual outcome after surgery was positively correlated with higher surgical coverage. CSR was positively correlated with cataract surgical coverage.

Conclusions:

Cataract surgical coverage is increasing in most countries at vision <3/60 and visual outcomes after cataract surgery are improving. Establishing population-based surveillance of cataract surgical need and performance is a strong monitoring tool and will help program planners immensely.

Characteristics of traumatic cataract wound dehiscence

PURPOSE

To characterize the clinical course of cataract wound dehiscence.

DESIGN

Retrospective, comparative case series.

METHODS

Charts of open globe injuries (848 injuries in 846 patients) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Time from original surgery to wound dehiscence, type of initial surgery, Ocular Trauma Score, age, gender, mechanism of injury, and visual acuity were analyzed.

RESULTS

Of 846 patients with 848 open globe injuries, 63 experienced cataract wound dehiscence. The majority of these cataract wounds (89%) were extracapsular cataract extraction (ECCE), with only 7 (11%) phacoemulsification wounds. The mean patient age in the wound rupture group was 78.2 years. Female patients comprised the majority (67%) of this subpopulation. The most common mechanisms of injury were fall (65%), blunt trauma (23%), and motor vehicle accident (7%). The median raw ocular trauma score was 47 in wound dehiscence patients. Visual acuity at presentation was light perception in the wound dehiscence group. The best postoperative visual acuity was significantly worse in the wound dehiscence group (hand motion) than in the remaining patients (20/40; P=.0002). When considering the phacoemulsification patients alone, these patients fared much better, with a median postoperative vision of 20/60.

CONCLUSIONS

Despite recent advances in cataract surgery, wound dehiscence remains a significant source of visual disability, mainly in the geriatric population. Rupture ECCE wound patients have a poor visual prognosis. Fortunately, patients with phacoemulsification site dehiscence appear to regain the majority of their vision after open globe repair.