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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 9-11

Visual outcome of difficult cataract surgeries in a tertiary care center in India


Department of Ophthalmology, BJ Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India

Date of Submission28-Oct-2016
Date of Acceptance07-Sep-2018
Date of Web Publication12-Mar-2019

Correspondence Address:
Smita Mohod Harne
D 902, Sicilia, B.T. Kawade Road, Ghorpadi, Pune - 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_99_16

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  Abstract 


Purpose: The purpose of this study is to determine the percentage of difficult cataracts out of total cataracts admitted in a tertiary care center, to study the intra- and postoperative complications in patients with difficult cataracts undergoing cataract surgery, and to determine their visual outcomes. Materials and Methods: This is a retrospective, noncomparative, single-institutional, observational study. The study was conducted on patients who were admitted over 2 years (January 2013–December 2014). Of these, patients with difficult cataracts (according to inclusion criteria) were screened and preoperatively evaluated. These patients underwent manual small incision cataract surgery and were followed up on the 1st, 7th, and 40th postoperative days. These cases were monitored for postoperative visual acuity (VA) and complications. The postoperative complications were graded according to the Oxford Cataract Treatment and Evaluation Team (OCTET) definitions and analyzed. Results: Of 5766 patients, 1858 (32.2%) patients presented with difficult cataracts. Hypermature and mature cataracts (24.9%), hard cataracts (20.02%), and pseudoexfoliation (33.04%) constituted as the major causes. Of these, 820 (44.1%) patients presented with no complications postoperatively. According to the OCTET grading, 44.9% of patients had Grade I, 9.5% had Grade II, and 1.83% had Grade III complications; the most common postoperative complication was corneal edema (39.2%). A total of 21.9% had VA <6/60 on postoperative day 1, which reduced to 5.27% on day 40 (P < 0.001). The patients with V/A >6/18 increased from 44.1% on day 1 to 61.8% on day 40 (P < 0.001). Conclusion: Visual morbidity remains high among patients with difficult cataracts, especially in patients with pseudoexfoliation and corneal pathology. Patients with hypermature cataract and Grade III–IV cataracts have a better visual outcome.

Keywords: Corneal degeneration, difficult cataract, hypermature cataract, pseudoexfoliation, zonular dialysis


How to cite this article:
Pande R, Harne SM, Bhuta N. Visual outcome of difficult cataract surgeries in a tertiary care center in India. J Clin Ophthalmol Res 2019;7:9-11

How to cite this URL:
Pande R, Harne SM, Bhuta N. Visual outcome of difficult cataract surgeries in a tertiary care center in India. J Clin Ophthalmol Res [serial online] 2019 [cited 2019 Jul 17];7:9-11. Available from: http://www.jcor.in/text.asp?2019/7/1/9/253995



India is a country with a large burden of blindness. Cataract contributes to 62.6% of the blind in the country.[1] In most cases, cataract gets detected at its early stage of development, and most patients undergo cataract surgery with minimal complications and good visual outcome. However, some patients are detected at later stages. Such difficult cataracts have always carried a poor visual prognosis due to higher intraoperative risks and higher postoperative complications associated with it. Thus, it is important to recognize the greater risk involved and act accordingly, to provide a better visual outcome to patients. This study was aimed at determining the percentage of difficult cataract out of total cataracts and studying the intra- and postoperative complications in patients with difficult cataract undergoing cataract surgery along with an assessment of postoperative visual outcomes in patients suffering from difficult cataract.


  Materials and Methods Top


This was a retrospective, single-institutional, observational study. It was conducted after obtaining approval from the ethical committee at our institution. All tenets of the Declaration of Helsinki were followed.

This study was conducted at an urban tertiary government hospital, located in Western India which also serves as a major referral center in this region. Patients from rural areas were referred to us through various eye camps and also from routine outpatient department. In this study, we have included cataract patients with the following diagnosis.

Inclusion criteria

The following criteria were included in the study:

  1. Hypermature cataract
  2. Grade IV–V cataract/hard cataract
  3. Subluxated lens
  4. Pseudoexfoliation
  5. Zonular dialysis
  6. Nondilating pupil
  7. Nebulomacular and leucomatous corneal opacities, peripheral corneal degeneration.


Combinations of >1 of the above criteria were seen in few patients. Such patients were categorized according to the predominant diagnosis.

Exclusion criteria

The exclusion criteria of this study were as follows:

  1. Traumatic cataract
  2. Pediatric cataract
  3. Associated with glaucoma
  4. Cataracts with high refractive error
  5. Corneal dystrophies.


The study was conducted on patients who were admitted over 2 years (January 2013–December 2014). Of these, patients with difficult cataracts (according to the inclusion criteria) were screened and preoperatively evaluated. Informed consents were taken, and all cases of difficult cataract underwent manual small incision cataract surgery (SICS) under local anesthesia. All patients were followed on 1st, 7th, and 40th postoperative days. These cases were monitored for postoperative VA and complications.

The complications on postoperative day 1 were graded according to the Oxford Cataract Treatment and Evaluation Team (OCTET) definitions:

  • Grade I: Trivial complications that may have needed medical therapy but were not likely to contribute to drop in VA
  • Grade II: Intermediate complications that needed medical therapy and were likely to result in marked drop in VA if left untreated
  • Grade III: Serious complications that would have needed immediate medical and surgical intervention to prevent gross visual loss.[2]



  Results Top


The study was conducted on a total of 5766 cataract patients. Of these, 1858 patients had difficult cataracts.

Distribution of difficult cataract cases based on the inclusion is given in [Table 1].
Table 1: Distribution of difficult cataract cases based on the inclusion criteria

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Intraoperative complications that occurred while performing manual SICS on difficult cataracts are described in [Table 2].
Table 2: Intraoperative complications that occurred while performing manual small incision cataract surgery on difficult cataracts

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Postoperative complications occurring on days 1, 7, and 40 are presented in [Table 3].
Table 3: Postoperative complications occurring on days 1, 7, and 40

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Distribution of patients according to postoperative VA on days 1, 7, and 40 are given in [Table 4].
Table 4: Distribution of patients according to postoperative visual acuity on days 1, 7, and 40

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Postoperative VA on days 1, 7, and 40, according to the preoperative diagnosis, is described in [Table 5].
Table 5: Postoperative visual acuity on days 1, 7, and 40, according to preoperative diagnosis

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Eight hundred and twenty (44.1%) patients presented with no complications on postoperative day 1.

According to the OCTET grading, 44.9% of patients had Grade I complications, 9.5% had Grade II complications, and 1.83% had Grade III complications.


  Discussion Top


A total of 32.2% (n = 1858) of patients presented with difficult cataracts. Hypermature and mature (24.9%) (n = 464) and hard cataracts (20.02%) (n = 372) constitute a significant volume of difficult cataracts in developing countries such as India. The lack of red reflex, high intralenticular pressure in intumescent cataracts, and leaking of lens matter from anterior capsule puncture sites account for greater surgical complexity intraoperatively. They are at a high risk for posterior capsule rent, zonular dialysis, and corneal endothelial damage. We found that the main intraoperative complication was posterior capsule rupture in such patients. Similar findings were made by Venkatesh et al., in their study on efficacy of manual SICS in treatment of patients with brunescent and white cataracts.[3],[4]

Pseudoexfoliation causes serious intraoperative complications due to pupil rigidity and zonular instability. In a study done by Jawad et al. on complications in cataract surgery due to pseudoexfoliation, it was established that an increased frequency of complications in these patients was due to zonular dialysis rather than capsular tears.[5] A total of 21% of the patients in our study had zonular dialysis which was diagnosed intraoperatively. Majority of the patients who presented with intraoperative zonular dialysis had pseudoexfoliation or hypermature cataracts preoperatively.

Cataract surgery in patients with corneal opacity and corneal degeneration is challenging because of low intraoperative visibility to the surgeon. These patients undergo further endothelial loss due to cataract surgery. This ultimately results in further corneal decompensation. A total of 6.08% (n = 113) of the patients in our study had corneal degeneration preoperatively. Peripheral opacities not obstructing visual axis were left untreated. Patients with central leucomatous opacities were managed by performing triple procedure (penetrating keratoplasty + cataract extraction + intraocular lens implantation).

The most common postoperative complication on day 1 was corneal edema (39.2%), followed by iritis (9.5%) and hyphema (5.1%). Patients with corneal edema were started on hyperosmotic ointment and eyedrops, which further reduced to 0.16% on day 40.

Postoperatively hypopyon occurred in 20 patients (1.07%), while endophthalmitis was seen in only 1 (0.05%) patient. Patients with iritis and hypopyon were treated with topical and systemic corticosteroids. All patients who had presented with iritis and hypopyon on days 1 and 7 responded to corticosteroids. This can be attributed to toxic anterior segment syndrome. Most patients with decentered intraocular lens underwent redialing postoperatively immediately.

After assessing the VA in all patients postoperatively and correlating them with their preoperative diagnosis, we discovered that patients with clear cornea, hypermature cataract, and some hard cataracts and few cases of pseudoexfoliation did not show any complication, thus having VA between 6/18 and 6/6 (P < 0.05). Majority of the patients with corneal degeneration and/or corneal opacity showed vision <6/60. Rest of the patients had VA between 6/60 and 6/18 depending on ocular comorbidity and surgical excellence. Limburg et al. made similar inferences in their study.[6]


  Conclusion Top


In spite of the best possible intra- and postoperative management provided to patients with difficult cataracts, visual morbidity among them remains very high. This is seen predominantly in patients with corneal pathology and pseudoexfoliation and those who suffer posterior capsular rent intraoperatively. Patients with hypermature cataract and Grade III–IV cataracts have a better visual prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
National Program of Control of Blindness and Visual Impairment; c2010. Available from: http://www.npcb.nic.in/. [Last updated on 2017 Oct 06; Last accessed on 2018 Aug 01].  Back to cited text no. 1
    
2.
Oxford Cataract Treatment and Evaluation Team. Use of a grading system in the evaluation of complications in a randomized controlled trial on cataract surgery. Br J Ophthalmol 1986;70:411-4.  Back to cited text no. 2
    
3.
Venkatesh R, Das M, Prashanth S, Muralikrishnan R. Manual small incision cataract surgery in eyes with white cataracts. Indian J Ophthalmol 2005;53:173-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Venkatesh R, Tan CS, Singh GP, Veena K, Krishnan KT, Ravindran RD, et al. Safety and efficacy of manual small incision cataract surgery for brunescent and black cataracts. Eye (Lond) 2009;23:1155-7.  Back to cited text no. 4
    
5.
Jawad M, Nadeem AU, Khan AU, Aftab M. Complications of cataract surgery in patients with pseudoexfoliation syndrome. J Ayub Med Coll (Abbottabad) 2009;21:33-6.  Back to cited text no. 5
    
6.
Limburg H, Foster A, Gilbert C, Johnson GJ, Kyndt M, Myatt M, et al. Routine monitoring of visual outcome of cataract surgery. Part 2: Results from eight study centres. Br J Ophthalmol 2005;89:50-2.  Back to cited text no. 6
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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