Manual suture less small incision cataract surgery in patients with uveitic cataract
Rahul Bhargava1, Prachi Kumar2, Hafsa Bashir1, Shiv Kumar Sharma3, Anurag Mishra1 1 Department of Ophthalmology, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India 2 Department of Pathology, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India 3 Department of Ophthalmology, Rotary Eye Hospital, Palampur, Himachal Pradesh, India
Purpose: The purpose of this study is to evaluate the outcome of manual small incision cataract surgery (SICS) in eyes with uveitic cataract. Setting: Medical college hospital of the subcontinent. Design: Retrospective case series. Materials and Methods: In this retrospective study, patients who underwent SICS with posterior chamber intraocular lens implantation for uveitic cataract from 2006 to 2009 were evaluated. Patients with less than 3 months follow-up were excluded. Post-operative vision and complications were analyzed. Results: A total of 54 patients completed the study. The mean age was 52.3 ± 9.3 years. The mean follow-up was 11.53 ± 5.05 months. The mean surgical time was (10.2 ± 3.8 min). Etiological diagnosis was possible in 31.41% (17/54) of patients. There was a statistically significant improvement in vision after surgery (P < 0.001). When uveitis was well-controlled, pre-operative corticosteroids did not change post-operative inflammation (P = 0.796). However, pre-operative corticosteroids were statistically significantly associated to final best corrected visual acuity (BCVA) (P = 0.010). Conclusion: SICS with posterior chamber intraocular lens implantation is safe in most cataracts due to uveitis and improves BCVA at 6 months. Inflammation should be well-controlled pre-operatively for at least 3 months. Posterior capsule opacification, macular edema and persistent uveitis were the main factors affecting visual outcome. SICS requires minimal instrumentation, surgical time is short and can also be performed in rural clinics and eye-camps, where phacoemulsification machines are unavailable. SICS may be a more practical and cost-effective technique for uveitic cataract, in such circumstances.
Keywords: Best Corrected Visual Acuity, Complicated Cataract, Posterior Capsule Opacification, Small Incision Cataract Surgery, Uveitis
How to cite this article: Bhargava R, Kumar P, Bashir H, Sharma SK, Mishra A. Manual suture less small incision cataract surgery in patients with uveitic cataract. Middle East Afr J Ophthalmol 2014;21:77-82
How to cite this URL: Bhargava R, Kumar P, Bashir H, Sharma SK, Mishra A. Manual suture less small incision cataract surgery in patients with uveitic cataract. Middle East Afr J Ophthalmol [serial online] 2014 [cited 2021 Oct 19];21:77-82. Available from: http://www.meajo.org/text.asp?2014/21/1/77/124110
Long standing ocular inflammation is often complicated by cataract formation. Location, severity of inflammation and treatment with corticosteroids are the responsible factors.  The incidence of cataract in uveitis varies from 57% in pars planitis to 78% in Fuchs heterochromic Cyclitis [Figure 1]a. , Cataract surgery is primarily indicated to visual rehabilitation and to address pathology in the posterior segment.
Poor pupillary dilatation and intraoperative complications due to synechia, pupillary membranes and bleeding from fragile vessels pose surgical challenges for the cataract surgeon. In additional, the outcomes of cataract surgery are difficult to assess as eyes with different types of uveitis respond differently to surgery. ,,
Despite being the preferred and more advanced technique of cataract surgery world-wide, phacoemulsification remains inaccessible to a vast majority of patients in rural and semi-urban settings in the sub-continent. Patients with uveitis are often referred to tertiary care centers for further management.
In the present study, we evaluated the outcomes of small incision cataract surgery (SICS) with posterior chamber intraocular implantation in uveitic cataract. We also explore the possibility of SICS as a cost-effective alternative to phacoemulsification in regions with limited access to phacoemulsification.
Materials and Methods
We retrospectively reviewed the hospital records of 54 eyes of 46 consecutive patients who underwent SICS with posterior chamber intraocular lens implantation (in the bag) for uveitic cataract, from 2006 to 2009.
Data collected include sex, age at surgery, etiology of uveitis, pre-operative findings such as best corrected visual acuity (BCVA) (using a Snellen chart) and corticosteroid intake, frequency and duration of quiescence of inflammation before surgery, surgical time and duration of follow-up, post-operative BCVA and presence of complications.
Exclusion criteria were less than 3 months follow-up, sulcus or sulcus-bag implantation of the intraocular lens, posterior capsule rent, traumatic and subluxated cataracts and diabetes mellitus.
The primary outcome measure was an improvement in visual acuity post-operatively. The secondary outcome measure was the rate of post-operative complications. The pre-operative protocol included routine investigations such as total and differential leucocyte counts, erythrocyte sedimentation rate and blood sugar levels, Mantoux test, chest X-ray, X-rays of the cervical spine and sacroiliac joints. Special investigations included rheumatoid factor, angiotensin converting enzyme essay, anti-nuclear factor, human leucocyte antigen typing and enzyme linked immunosorbant assay for toxoplasmosis, human immunodeficiency virus and tuberculosis. B-scan ultrasonography was performed in cases where funduscopy was not possible due to dense cataract. Intraocular pressure was measured with applanation tonometry. Sure shot etiological diagnosis was marked when found.
Aqueous flare and cells were graded with a modified Hogan's technique. , Vitreous cells were graded with the classification proposed by Bloch-Michel and Nussenblatt and Nussenblatt et al.,
A minimum inflammation free period (anterior chamber [AC] and vitreous) of 3 months was a pre-requisite for eligibility for surgery. All surgeries were performed by one surgeon who was fellowship trained.
Oral prednisolone, 1 mg/kg body weight was given 7 days prior to surgery, continued post-operatively and tapered according to the inflammatory response over 4-6 weeks in the following conditions:
Previously documented macular edema
Chronic anterior uveitis
Informed consent was obtained from all subjects (or their guardians) prior to surgery. The research protocol was approved by the Ethics committee Ghaziabad district, India.
The surgical technique was as follows, peribulbar anesthesia was delivered. A side port entry was made at the 10 O' clock position with a 20 G micro vitreo-retinal surgery (MVR) or a 15° angled knife. A 5.5-6 mm frown incision was made on the sclera, 2 mm posterior to the limbus in superior quadrant. The depth was slightly less than half the scleral depth. A self-sealing (tri-planar) sclero-corneal tunnel was made with a 2.2 mm bevel up crescent knife with adequate side pockets. The AC was formed with viscoelastic. AC entry was performed and enlarged with a 2.8 mm keratome. In non-dilating pupils, synechiolysis was performed with an iris repositor. Sphincterotomy was performed at the 3, 6, 9 O'clock positions. Adjunctive trypan blue dye was used to stain the anterior capsule in dense cataracts. A continuous curvilinear capsulorrhexis was intended in all cases. Hydrodissection was performed a with a 2 cc syringe attached to a 25 G cannula. The nucleus was rotated in the bag with a bent capsulotomy needle and prolapsed into the AC. The nucleus was delivered by the sandwich technique. Lens matter aspiration was performed with a Simcoe cannula. Polymethyl methacrylate lens with a 5.5 mm optic was implanted using a double dialing technique. In the bag placement was performed in all cases.
Post-operatively, patients received 0.5% topical Moxifloxacin 6 times a day, 1.0% atropine 3 times a day and 0.1% topical betamethasone hourly that was tapered over 10-12 weeks. Topical Flurbiprofen 0.5% was used selectively, 3 times a day in patients who developed cystoid macular edema; these patients also received topical corticosteroids.
Patients were followed-up on day 1, 7, 21, 30, 90 and 180. At each visit, BCVA, aqueous cells and flare, red reflex and fundus details were recorded.  Patients taking systemic corticosteroids underwent monitoring of blood sugar, blood pressure and urine analysis.
The visual acuity at 6 weeks, 6 months and at the final follow-up visit was recorded. Statistical analysis was performed with the Pearson Chi-square test and McNemar Bowker tests. The P value was calculated at 1% and 5% levels. A P value less than 0.001 at 1% and less than 0.005 at 5% was considered statistically significant.
A total of 10 cases were excluded from the study due to follow-up less than 3 months. In addition, 4 patients were lost to follow-up. The records of 54 patients were analyzed after exclusion. The mean age was 52.3 ± 9.3 years. The mean follow-up was 11.53 ± 5.05 months.
Males had a slightly better (but not statistically significant) visual outcomes compared with females (P = 0.097). Etiological diagnosis was possible in 31.41% (17/54) of patients.
Final visual acuity was compared with pre-operative visual acuity [Table 1] and [Figure 1]b. At 6 months, BCVA improved by three or more Snellen lines in 92.59% (50/54) patients. This improvement in vision after surgery was statistically significant at the 1% level (Chi-square test [P < 0.001]).
Patients who used pre-operative corticosteroids had significantly better final visual acuity than patients who did not used pre-operative corticosteroids (P < 0.001). However, final BCVA was comparable in both groups [Table 2].
The final visual outcome was not significantly influenced by the anatomical location of uveitis or the etiological diagnosis (P = 0.028 and P = 0.062 respectively).
The pre-operative and final BCVA was compared for patients requiring additional procedures [Table 3] and [Figure 1]c such as vitrectomy, epiretinal membrane peeling, neodymium yttrium aluminium garnet laser capsulotomy etc., There was a significant improvement in vision following these procedures (P < 0.001).
Pre-operatively, 51.9% (28/54) of patients received corticosteroids. Ten (18.5%) eyes received topical corticosteroids, 4 times daily, 1 week prior to surgery. Topical non-steroidal anti-inflammatory drops were prescribed in 11 (20.37%) eyes.
Post-operatively, patients were instructed to instill topical corticosteroids every hour when awake and the dose was tapered over 6-8 weeks. Of the 28 eyes that received pre-operative medications, 21.42% (6/28 eyes) developed increased post-operative inflammation that required oral corticosteroids. Two eyes received additional periocular triamcinolone injection for control of inflammation. Of the 26 eyes that did not receive pre-operative medications, 7.69% (2/26 eyes) developed increased post-operative inflammation and required additional medication. None of the eyes required systemic immunosuppressive therapy.
Pre-operative medications did not significantly change post-operative inflammation when uveitis was well controlled (Chi-square test, P = 0.796).
Posterior capsule opacification (PCO) (16.67%) and macular edema (14.81%) were the most common causes of reduced vision [Table 4]. Of the four eyes with chronic anterior uveitis, which received topical steroids pre-operatively, 2 eyes developed macular edema post-operatively.
Table 4: Causes of reduced vision post-operatively
Cataract surgery in patients with uveitis not only provides visual rehabilitation, but also visualization of the posterior segment [Figure 1]d. Intraocular lens implantation can be safely performed in most cases of uveitic cataract with the possible exception of juvenile chronic arthritis. ,
To date, there are no reports in the literature of SICS for uveitic cataract (MedLine search).
In developing countries, there is a large burden of cataracts and a relative shortage of eye surgeons. Manual small-incision cataract surgery is faster (11.6 ± 3.8 min) and offers an alternative to technically difficult phacoemulsification cases such as a miotic pupil and extensive posterior synechia. SICS obviates the need to convert to extra capsular cataract extraction (ECCE).
In addition, phacoemulsification machines are expensive and there is cost associated with use and maintenance. This gives manual SICS a financial edge over phacoemulsification as the preferred modality for cataract extraction. 
In our study, SICS resulted in an improvement in BCVA in 92.59% (50/54) eyes by three or more Snellen lines at 6 months post-operatively. Okhravi etal.  found improvement in 90% eyes, 6 months post-operatively (ECCE) in patients with uveitic cataract. Ram etal.  found improvement in 91.6% patients (phacoemulsification). Our results are comparable with these studies [Table 5].
A study from the Indian subcontinent by Hazari and Sangwan  reported a series of 106 eyes with uveitic cataract that underwent cataract surgery (ECCE 93/106, 87.73% and phacoemulsification 11/106, 10.3%) with or without implantation. Hazari and Sangwan  reported that 86.7% (92/106) of eyes improved by 3 or more Snellen lines at 6 months post-operatively. These outcomes are comparable with our study (93%) [Table 5].
In other retrospective studies, the number of eyes with an improvement in BCVA at 6 months, after phacoemulsification, ranges from 85% to 95% [Table 5].
We found no statistically significant influence of pre-operative medication on post-operative inflammation (P > 0.05) when uveitis was well controlled pre-operatively. This finding was similar to a retrospective study by Hazari and Sangwan. 
Final BCVA was comparable in patients with or without pre-operative corticosteroid use. Neither anatomical location, nor the type of uveitis influenced final post-operative visual outcome. Thus, the single most important factor appears to be good inflammation control and a quiescent, inflammation-free course of at least 3 months prior to surgery. Absence of disease activity in both the anterior and posterior chamber was considered synonymous with inflammatory control.
The frequency of PCO in our study was 16.67% (9/54), which is lower than the rate reported in previous studies. PCO requiring neodymium-doped yttrium aluminum garnet (Nd: YAG) laser capsulotomy was reported in 28.70% eyes by Ram etal., in 31% of eyes by Estafanous etal., in 33% of eyes by Okinami etal. and in 23.7% of eyes by Kawaguchi etal. ,,, The lower incidence in our study could be due to in-the-bag intra-ocular lens implantation in all our patients. In additional, the duration of follow-up in our study was shorter as compared with other studies. Nd: YAG laser capsulotomy was performed after a quiet post-operative period of 3 months. However, there was no statistically significant correlation between PCO and increased post-operative inflammation (P > 0.05).
Macular edema (14.81%) was a common cause of decreased vision post-operatively [Figure 1]e. Ram etal. report incidence of macular edema of 21.3% and Estafanous etal. reported 33%, following phacoemulsification. , In-the-bag IOL implantation and good pre-operative control of inflammation could explain the decreased incidence in our study. Severe uveitis was associated with an increased incidence of macular edema. There was a statistically significant reduction in the rate of macular edema [Table 6] in patients pre-operatively treated with oral corticosteroids (P < 0.001). This finding was similar to that of Jancevski and Foster. 
Incidence of persistent uveitis (11/54) 5.94% was lower, as comparable to that reported by Okhravi etal.  The probable cause of persistent uveitis was disease activity in the vitreous, which could not be appreciated (after B-scan) due to the dense cataract despite a quiet AC. This finding highlights the importance of good control of inflammation prior to surgery.
The mean surgical time in our study (10.2 ± 3.8 min) was slightly greater compared with a randomized study by Venkatesh etal. (8.8 ± 3.4 min) in SICS group versus (12.2 ± 6.6 min) in phacoemulsification group.  This difference is likely due to the additional procedures to dilate pupil such as synechiolysis and sphincterotomy there were required in our study (uveitic cataracts) as opposed to the age related cataract treated by Venkatesh etal. 
The limitations of the present study include a short follow-up (11.53 ± 5.05 months) and a (non-randomized) study design that does not allow for comparison of SICS with phacoemulsification. However, there are no published randomized controlled trials comparing phacoemulsification and manual SICS for uveitic cataract (MedLine search).
Predictably good visual outcome can be achieved by SICS and posterior chamber intraocular lens implantation in uveitic cataract, compared with conventional ECCE and phacoemulsification. The key to success is good patient selection, counseling and adequate pre-operative control of inflammation. Although phacoemulsification is the preferred modality of cataract surgery worldwide, it is still not available in some regions within developing countries such as India. Manual SICS is faster, can be performed with minimal instrumentation, even in a rural and semi-urban settings and in eye-camps. Thus, it provides an economic advantage and may also be the appropriate technique in eyes with uveitic cataract in countries in this sub-continent.
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