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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 2  |  Page : 215-222

Comparative study of visual outcome, astigmatism, and complications between conventional extracapsular cataract extraction and manual small incision cataract surgery


Department of Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India

Date of Submission22-May-2020
Date of Decision05-Jun-2020
Date of Acceptance10-Jun-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Sumant Shekhar
226, Road No. 4, Ashok Nagar, Ranchi - 834 002, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_201_20

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  Abstract 


Context: Comparative study of visual outcome, astigmatism, and complications between conventional extracapsular cataract extraction (CECCE) and manual small incision cataract surgery (MSICS). Aims: To study and compare the visual outcome, astigmatism, and complications between CECCE and MSICS. Settings and Design: This is a hospital-based, prospective, case–control observational study of 2 years' duration; 110 eyes of 110 patients with cataract attending the ophthalmology outpatient department/inpatient department at Acharya Vinoba Bhave Rural Hospital were selected for the study after taking the inclusion and exclusion criteria into consideration. Informed consent was obtained from all subjects after approval by the institutional ethical committee of the college. Materials and Methods: After enrollment, the patients were divided into two groups, one which underwent cataract extraction by CECCE and other which underwent cataract extraction by MSICS. All surgeries were done by the same surgeon under same setting, and visual outcome, astigmatism, and complications were studied and compared between the two groups. Statistical Analysis Used: Statistical analysis was carried out using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test and software used in the analysis was SPSS 17.0 version and Graph Pad 6.0 version and P < 0.05 is considered as level of significance. Results: Patients who underwent cataract extraction by MSICS had better and early visual rehabilitation. Surgically induced astigmatism (SIA) in MSICS was comparatively less as compared to CECCE. In terms of complications, not much difference was noted between the two groups. Conclusions: In the present study, we found that MSICS needs to be a better surgical procedure for cataract extraction as compared to CECCE in terms of better and early visual rehabilitation and lesser SIA.

Keywords: Astigmatism, cataract, extracapsular cataract extraction, small incision cataract surgery, visual acuity


How to cite this article:
Shekhar S, Tidake PK. Comparative study of visual outcome, astigmatism, and complications between conventional extracapsular cataract extraction and manual small incision cataract surgery. J Datta Meghe Inst Med Sci Univ 2020;15:215-22

How to cite this URL:
Shekhar S, Tidake PK. Comparative study of visual outcome, astigmatism, and complications between conventional extracapsular cataract extraction and manual small incision cataract surgery. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 26];15:215-22. Available from: http://www.journaldmims.com/text.asp?2020/15/2/215/304248




  Introduction Top


”The eye is the window of the human body through which it feels its way and enjoys the beauty of the world.”

– Leonardo Da Vinci

Cataract comes from the Greek word “υπόχυσις” (kataráktēs), meaning the fall of water. Any opacity in the lens and/or its capsule whether congenital, developmental, or acquired which causes visual impairment is called a cataract.

There are an estimated number of people with visual impairment in excess of 161 million, in which 37 million are blind and 124 million are suffering from low vision. In the world, the leading cause of blindness is cataract.[1] It is the foremost cause of treatable blindness in India as well as the world. The number of cataract in India in a year is around 3.8 billion,[2] and only 1.8 million cataract surgeries are being done annually.[3]

The technique of cataract surgery has been developing and changing in the past two decades. The resurgence of extracapsular cataract surgery historically has been the most effective and least traumatic method of treating cataracts.

There have been sporadic and constant efforts through the centuries for novel surgical options to treat cataract. Behind all these efforts, the sole aim was to restore the patient's vision to the precataract levels with a cure of all other symptoms.

In India, the majority of patients are poor are not in a position to afford procedures, such as phacoemulsification which are available at a premier rate due to high cost of phaco machines. Historically, extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens implantation (PCIOL) has been considered an efficacious method of restoring vision and bettering the quality of life in developing countries. In spite of its effect on restoring vision, it is hard to ignore its problems related to large incision, suturing of wound, and complications related to suturing with delayed visual rehabilitation. In recent studies, it has been observed that both conventional ECCE (CECCE) and manual small incision cataract surgery (MSICS) are safe and effective for the treatment of cataract surgery. However, MSICS gives better-uncorrected vision. In this context, MSICS is becoming popular as its proving itself to be an inexpensive alternative to phaco.

Nevertheless, cataract surgery is full of challenges. Continuous attempts are being made to overcome these challenges. The aim nowadays in cataract surgery is to make the patient emmetropic and surgically correct the preoperative and induced astigmatism. Thus, nowadays considered as refractive cataract surgery.

Recently, most of the cataract surgeries in the developing countries including India were performed by CECCE, but disadvantages of CECCE such as large incision, delayed visual rehabilitation, large surgical-induced astigmatism (SIA), and sutural complications have made surgeons look for other alternate procedures. MSICS has emerged as an inexpensive option because of the advantages of early visual rehabilitation, less SIA, and no suture-related complications.

The main goal point of modern cataract surgery is to induce minimal astigmatism, restore vision at the earliest, and provide best corrected visual acuity. The dictum today in the rehabilitation of a patient of cataract is “small is beautiful.”[4]

One of the most important elements for consideration of visual rehabilitation is SIA, which is governed by the interaction of wound gape and compression, which in turn are affected by the nature of incision, i.e., location, size, and type of suture used.

Astigmatism in an operated eye with an intraocular lens implant is most undesirable since it reduces the effectiveness of the procedure. It is therefore worthwhile with these eyes to have an operating method that minimizes astigmatism, even though it requires more skill for the surgeon. To fulfill the goal of VISION 2020: The right to sight advancement in cataract surgery is necessary, especially in developing and underdeveloped countries.

It is a proven fact that for more than a century, incision of cataract surgery has had a major influence on induced astigmatism. Significant astigmatism may be visual debilitating, causing a decrease in visual acuity, glare, monocular diplopia, and asthenopia. Constant efforts have been made to minimize and reduce SIA. SICS is one of the most innovative and popular techniques.[5] The whole idea of small incision is based on the fact that it is necessary to reduce SIA for obtaining minimal and stable postoperative refraction.[6]

Constant improvements are being made in the technique to cataract extraction to decrease SIA. Main ingredients responsible for SIA are the type of incision and its location, size, and contour, approach to wound closure, and the technique used for it. The most important factor among this affecting SIA is the location of incision[7] which when being perpendicular to the direction of incision there is flattening of cornea.[8] It has been observed that more the distance for the cataract incision from the visual axis, lesser is the change in the corneal curvature. The geometry of the wound has a compelling impact on the surgical outcome.[9]

Hence, we want to study and compare the visual outcome, astigmatism, and complications produced by CECCE and MSICS.


  Materials and Methods Top


The study adhered to the tenets of the Declaration of Helsinki, and it was approved by an institutional ethical committee of DMIMSU. Informed consent was obtained from all subjects after nature, and possible consequences of the study were explained to them.

Settings

All the procedures and surgery were conducted at the Department of Ophthalmology, Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi.

Research design

This was a prospective, randomized, interventional study.

Participants

All patients attending with senile cataract coming to the Ophthalmology Outpatient Department (OPD) of AVBRH were selected for surgery after taking inclusion and exclusion criteria into consideration.

Inclusion criteria

  • Patients aged more than 18 years
  • Randomly selected cataract patients coming to the eye OPD of AVBRH
  • Patients with nuclear sclerosis grade 1/2/3 are selected for MSICS and CECCE all grade of cataract are selected
  • Patients were selected, irrespective of sex.


Exclusion criteria

  • Patients equal to and more than grade 4 nuclear sclerosis in the MSICS group
  • Patient aged <18 years
  • Pediatric cataract
  • Patients with coexisting glaucoma
  • Patients with uveitis
  • Patients with subluxated lens
  • Patients with posterior segment pathology
  • Aphakic patients
  • Patients with keratoconus
  • Patients with corneal pathology
  • Patients with connective tissue disorders
  • Patients with traumatic cataract.


Sample size

Using sample size formula with desired error of margin, n = Z2 α/2 × P × (1 − P)/d2, where Zα/2 is the level of significance at 5%, i.e., 95% confidence interval = 1.96, P = prevalence of cataract = 7.39% , and D = Desired error of margin = 7% = 0.07,

n = 1.962 × 0.0739 × (1 − 0.0739)/0.072

= 53.65

= 55 patients needed in each group.

A minimum of 110 patients (55 eyes of 55 patients of CECCE and 55 eyes of 55 patients of SICS) was calculated.

Ethical issues

The institutional ethical committee approved the study. This study adhered to the tenets of Helsinki.

General examination

General vital data such as pulse, blood pressure, and peripheral pulses were noted; higher function status was also documented.

Ocular examination

This was a prospective study of 110 consecutive patients assigned to undergo conventional extracapsular cataract excision surgery (55 cases) and MSICS (55 cases). The study was done for a period of 2 years (September 2017 to 2019) at AVBRH. Institutional ethics committee permission was taken. Furthermore, informed consent was obtained from each patient.

Patients were admitted 1 day before the surgery. A detailed history was taken of each patient, and thorough anterior segment examination was performed using a slit lamp. Visual acuity was checked with Snellen's visual acuity chart, and pinhole improvement was noted. After pupillary dilatation, detailed fundus examination was done by direct ophthalmoscopy, indirect ophthalmoscopy, and slit-lamp biomicroscopy. Lenticular opacity was assessed and graded. Intraocular pressure was measured with Schiotz tonometer/noncontact tonometer, and patency of the lacrimal system was checked. Keratometry was carried out using the Topcon automated keratometer. Axial length was measured by A-scan unit, and intraocular lens power was calculated using the SRK II formula. Routine investigations were done to rule out diabetes and hypertension.

All patients received antibiotic eye drops hourly 1 day before the surgery. All patients received oral antibiotic, ciprofloxacin 500 mg twice daily or ofloxacin 200 mg twice daily for 3 days starting from the day of surgery.

Preoperative adequate mydriasis was achieved with instillation of tropicamide 0.8% with phenylephrine 5% and flurbiprofen 0.03% eye drops 1 h before surgery for every 15 min. Pediatric cataract and cases with traumatic cataract, complicated cataract, cataract associated with glaucoma, and corneal disorders were excluded. All cases were done under local peribulbar anesthesia by a single surgeon. In MSICS group, only frown incision was taken.

A detailed postoperative examination of the patients was done at 1st day, 3 weeks, and 6 weeks. The examination including checking visual acuity, keratometry, slit lamp biomicroscopy, direct ophthalmoscopy, indirect ophthalmoscopy, and postoperative complications was noted. At the end of 6 weeks, a final best-corrected subjective refraction was performed and the spectacles prescribed. All the changes in the keratometry readings were recorded and tabulated for each corresponding period. SIA was calculated using vector analysis method.

Statistical analysis

Statistical analysis was done using descriptive and inferential statistics using Chi-square test and one-way ANOVA and software used in the analysis was Statistical Product and Service Solutions version (SPSS Statistics for Windows, version x.0, SPSS Inc., Chicago, Ill, USA) and GraphPad Prism 7.0 version (GraphPad Software, 2365 Northside Dr., Suite 560, San Diego, CA 92108, USA) and P < 0.05 is considered as the level of significance.

Ethical Approval

Ethical approval for this study (DMIMS(DU)/IEC/2017-18/6660) was provided by the Ethical Committee of Datta Meghe Institute of Medical Sciences (Deemed to be University) on 4/09/17.


  Results Top


A randomized prospective comparative study in two groups, one group which underwent cataract surgery by CECCE and the other group which underwent cataract surgery by MSICS.

A total of 110 cases were studied, in which 55 cases underwent conventional CECCE and 55 cases underwent MSICS. The visual outcome, astigmatism, and complications were noted and compared between the two groups.

The majority who underwent cataract surgery were in the age group of 60–69 years. The mean age of patients in the CECCE group was 66.12 ± 7.49 and that in the SICS group was 64.43 ± 7.32.

[Table 1] compares the visual acuity preoperatively as well as postoperatively between CECCE and MSICS.
Table 1: Comparison of visual acuity

Click here to view


[Table 2] and [Figure 1]a and [Figure 1]b depict the changes in astigmatism preoperative period as well as in the follow-up period postoperatively between CECCE and MSICS. In the preoperative period, the majority of the patients in both CECCE and MSICS group had against the rule (ATR) astigmatism. In CECCE in the postoperative follow-up, there was a major shift to with the rule (WTR) astigmatism. In MSICS group, in the postoperative period, the majority of the patient had ATR astigmatism.
Table 2: Comparison of astigmatism preoperatively as well as postoperatively between conventional extracapsular cataract excision and small incision cataract surgery

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Figure 1: (a) Comparison of postoperative astigmatism in conventional extracapsular cataract extraction group. (b) Comparison of postoperative astigmatism in small incision cataract surgery group

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[Figure 2] compares the mean astigmatism in between CECCE and MSICS. In CECCE group, the mean preoperative astigmatism was 1.07 D which increased to 3.51 D in week 1 and decreased to 1.36 D by the end of 6 weeks. In the present study, in terms of mean astigmatism, in the MSICS group, the mean preoperative astigmatism was 0.73 D which increased to 1.18 D in week 1 and decreased to 1.25 D by the end of 6 weeks.
Figure 2: Graphic representation of mean postoperative astigmatism

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[Table 3] and [Figure 3]a and [Figure 3]b compare the SIA between CECCE and MSICS. In the present study, the SIA was WTR in the CECCE group. The induced astigmatism in MSICS group was ATR.
Figure 3: (a) Surgically induced astigmatism in extracapsular cataract extraction group. (b) Surgically induced astigmatism in small incision cataract surgery group

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Table 3: Comparison of surgically induced astigmatism between conventional extracapsular cataract excision and small incision cataract surgery group

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[Table 4] and [Figure 4] show the mean SIA comparison between CECCE and MSICS. In the present study, in terms of mean SIA in the CECCE group, in week 1, the mean SIA was 4.30 ± 1.53 D which decreased to 1.94 ± 1.09 D by the end of 6 weeks postoperatively. In the present study, in terms of mean SIA in MSICS group, in week 1, the mean SIA was 1.11 ± 0.67 D which decreased to 1.24 ± 0.85 D by the end of 6 weeks postoperatively.
Figure 4: Graphical representation of comparison of mean surgically induced astigmatism between conventional extracapsular cataract extraction and small incision cataract surgery

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Table 4: Mean surgery-induced astigmatism comparison between conventional extracapsular cataract excision and small incision cataract surgery group

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[Table 5] and [Figure 5]a and [Figure 5]b show the type of SIA and amount of induced astigmatism in the CECCE group. In the present study, in the CECCE group, 56.36% had WTR astigmatism in the range of 2.1–4 D in week 1, while 50.91% had WTR astigmatism in the range of 2.1–4 D and 27.27% had astigmatism in the range of 0.6–2 D in week 3. In week 6, there was a shift in the range of astigmatism. Majority of the patients by 6 weeks postoperatively had astigmatism in the range of 0.6–2.0 D.
Figure 5: (a) With the rule surgically induced astigmatism in extracapsular cataract extraction group. (b) Against the rule surgically induced astigmatism in extracapsular cataract extraction group

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Table 5: Type of surgery-induced astigmatism and induced astigmatism in conventional extracapsular cataract excision group

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[Table 6] and [Figure 6]a and [Figure 6]b show the type of SIA and amount of induced astigmatism in the MSICS group; in the present study, the majority of patients in the MSICS group belonged to ATR astigmatism. In week 1, majority of the patients (61.82%) had ATR astigmatism in the range of 0.6–2.0 D, which increased to 81.82% by week 3 and decreased to 52.73% by week 6 postoperatively.
Figure 6: (a) With the rule surgically induced astigmatism in small incision cataract surgery group. (b) Against the rule surgically induced astigmatism in small incision cataract surgery group

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Table 6: Type of surgery-induced astigmatism and induced astigmatism in small incision cataract surgery group

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[Table 7] and [Table 8] compare the intraoperative as well as postoperative complications between CECCE and MSICS [Table 9] and [Table 10].
Table 7: Intraoperative complication between conventional extracapsular cataract excision and manual small incision cataract surgery group

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Table 8: Comparison of postoperative complication between conventional extracapsular cataract excision and manual small incision cataract surgery group

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Table 9: Comparable studies for conventional extracapsular cataract excision

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Table 10: Comparable studies for manual small incision cataract surgery

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  Discussion Top


The inclusion of a higher number of female patients (55.5%) in our study was similar to the study done by Gurung et al.[10] (52.3% vs. 47.7%) and Venkatesh et al.[11] (54% vs. 46%). By the end of 6th week, majority of the patients (56.36%) in the MSICS group had visual acuity in the range of 6/6–6/12, whereas majority (70.91%) of the patients in the CECCE group had visual acuity in the range of 6/18–6/36. Therefore, in the present study, it is seen that better visual rehabilitation is seen in the MSICS group rather than CECCE group by the end of 6th week. This result was compared with the study done by Hennig et al., in which they reported uncorrected visual acuity of 6/18 or better in 76.8% at discharge and 70.5% at 6 weeks. Corrected visual acuity of 6/18 or better was found in 96.2% at 6 weeks. The poor uncorrected visual outcome of <6/60 was seen in <2% of cases. The main cause was high AIR astigmatism.[12] Gogate et al., in a study of 706 eyes, reported uncorrected visual acuity of 6/18 or better at 6 weeks in 37.3% and 47.9% in the CECCE with PCIOL and MSICS, respectively, which is slightly more in the present study.[13] In CECCE in the postoperative period, there was a major shift to WTR astigmatism. This is explained by the fact that sutures cause steepening along the meridian of the incision. Too many sutures, deep bites, excessive tension applied all predispose to WTR shift and have a direct relation with the magnitude of induced astigmatism. In the MSICS group, in the postoperative period, the majority of the patients had ATR astigmatism. In a study done by Laxmiprasad et al., 67.75% of the patients in CECCE group had WTR astigmatism on the 1st postoperative day, and 77.55% in MSICS group had ATR astigmatism which is comparable to the present study.[14] In a study done by Padamukhi et al., majority of cases in the CECCE (68%) had ATR astigmatism, while in comparison (P < 0.01 significant) to MSICS group where WTR and ATR cases were almost equal. The finding in case of CECCE was similar to the finding observed in our study.[15] In the present study, in terms of mean astigmatism, the mean preoperative astigmatism in CECCE group was 1.07 D decreased to 1.36 D by the end of 6 weeks and the mean preoperative astigmatism in MSICS group was 0.73 D decreased to 1.25 D by the end of 6 weeks. In the study done by Bigyabati et al., at the first follow-up (2 weeks) in the present study, the mean (standard deviation [SD]) postoperative astigmatism was 3.48 ± 1.7 D in the CECCE group and 1.77 ± 0.9 D in the SICS group which is comparable to the present study.[16] In the present study, the SIA was WTR in the CECCE group. The induced astigmatism in the MSICS group was ATR. In study done by Padamukhi et al., postoperatively, majority of the patients had WTR astigmatism in 40 patients (80%) at the 6th week, 30 patients (60%) at the 3rd month in CECCE and ATR astigmatism in 38 patients (76%) at the 6th week and 41 patients (82%) at the 3rd month in the MSICS group. This was comparable to the present study.[15] In a study done by Khanday et al. in terms of SIA, 1st-week postoperatively in the CECCE group, 96% had WTR astigmatism; in further follow-up, in the 3rd week, there was no change; whereas in the 6th week, 90% had WTR astigmatism and 4% had ATR astigmatism. This is comparable to the findings in the present study.[17] In the present study in terms of mean SIA in the CECCE group, the mean SIA at week 1 was 4.30 ± 1.53 D which decreased to 1.94 ± 1.09 D by the end of 6 weeks postoperatively. In the present study in terms of mean SIA in the MSICS group, the mean SIA at week 1 was 1.11 ± 0.67 D decreased to 1.24 ± 0.85 D by the end of 6 week postoperatively. Khandey et al. found that the mean SIA in the SICS group during the 1st postoperative week was found to be 1.60 ± 0.90 SD compared to 4.00 ± 1.23 SD in the ECCE group. This is comparable to the present study.[17] In the present study, majority of patients in the ECCE group had WTR astigmatism.

In the MSICS group, the majority of the patient had ATR astigmatism. In the CECCE group, 61.82% of the patients had ATR astigmatism in the range of 61.82% and a similar observation was seen at week 3 and week 6.


  Conclusion Top


In a study done by Khanday et al., at 1st week postoperatively, 76% in the SICS group had SIA of <2 D whereas 94% in the ECCE group had SIA of magnitude > 2 D. This is comparable to the present study.[17] In study done by Khanday et al. at 3rd week postoperatively, 60% in the SICS group had SIA of <1 D whereas 82% in the ECCE group had SIA of magnitude >2 D. This is comparable to the present study.[17] In a study done by Khanday et al. at 6th week postoperatively, 56% in the ECCE group had SIA of <2 D whereas no patient in the SICS group had SIA of magnitude >2 D. This is comparable to the present study.[17],[18],[19],[20],[21],[22],[23]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Laxmiprasad G, Shori C, Shori R, Alli A. Comparative study between conventional extra capsular cataract extraction versus manual small incision cataract surgery. Int J Res Med Sci 2017;5:996-1001.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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