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Necessity of conjunctival flap in manual sutureless small-incision cataract surgery
CORRESPONDENCE
3. Jin GJC, Crandall AS, Jones JJ. Intraocular lens exchange due to incorrect lens power. Ophthalmology 2007; 114:417–424 4. Porter J. Incorrect IOL selection [letter]. Ophthalmology 2006; 113:883 5. Burks R. How can this happen? [letter] Ophthalmology 2005; 112:2057 6. Saufl NM. Universal protocol for preventing wrong site, wrong procedure. J Perianesth Nurs 2004; 19:348–351 7. Kohnen S. Postoperative refractive error resulting from incorrectly labeled intraocular lens power. J Cataract Refract Surg 2000; 26:777–778
OTHER CITED MATERIAL A. Hong Kong Hospital Authority. HA Convention 2008 – A New Era of Patient Care, 2008. Available at: http://www.ha.org.hk/haho/ ho/pad/080505-HA-Eng.pdf. Accessed April 6, 2012
Necessity of conjunctival flap in manual sutureless small-incision cataract surgery Punitkumar Singh, MS, Subhadra Singh, MS, Gajesh Bhargav, MS, Manju Singh, MS Online Video High-volume phacoemulsification is difficult in developing countries because the technology requires costly machinery and consumables. Manual smallincision cataract surgery (SICS) is comparable to phacoemulsification in achieving excellent visual outcomes with low complication rates and is significantly faster and less expensive.1–4 The basis of manual SICS is the tunnel construction. By convention, a fornixbased conjunctival flap is considered a requirement. PATIENTS AND METHODS Two hundred twenty eyes of 190 patients having manual SICS were randomized into 2 groups. Group 1 (110 eyes) had manual SICS without a conjunctival flap, and Group 2 (110 eyes) had manual SICS with a fornix-based
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conjunctival flap. The intraoperative complications, surgical time, and findings immediately postoperatively and at 45 days and 3 and 6 months were noted and compared using the 2-sample t test between percentages.
Technique in Group 1 A number 11 blade on a Bard-Parker handle (American Ophthalmic Laboratories LLC) was used to make the incision groove directly through the conjunctiva, Tenon, and sclera up to one-third to one-half the scleral thickness, 2.0 to 3.0 mm behind the corneoscleral limbus (Figure 1; Video, available at http://jcrsjournal.org). Cautery was not used and any bleeding was washed away with continuous irrigation. The pocket tunnel was dissected. After routine manual SICS, subconjunctival amikacin and dexamethasone were injected above and below the incision/groove to cause adequate conjunctival ballooning.
Technique in Group 2 A fornix-based conjunctival flap was created starting from the limbus, and electric bipolar cautery was done. At the end of the procedure, the conjunctival flap was reapproximated at the limbus with bipolar cautery.
RESULTS The surgical time was markedly less in Group 1 (mean 7.67 minutes G 1.45 [SD]) than in Group 2 (mean 11.46 G 1.69 minutes) using the independent groups t test between means (P!.001). Intraoperative pupillary miosis was significantly greater in Group 1 (PZ.039). There were more patients with a subconjunctival bleed involving more than 1 quadrant of the bulbar conjunctiva on the first postoperative day in Group 1 than in Group 2, and the difference was statistically significant (P!.0001). Reassurance was all that was required in most cases. Postoperative conjunctival retraction and consequent wound exposure were also significantly higher in Group 1 (PZ.026), but neither endophthalmitis nor infectious iritis was noted in any case on
Figure 1. A: Number 11 blade on a Bard-Parker handle is used to create a groove directly through the conjunctiva and Tenon into the sclera. B: As the groove is formed, the conjunctiva may retract above and below the wound to give a clearer view of the scleral groove. C: A scleral tunnel is formed under the conjunctiva using a disposable metal crescent. J CATARACT REFRACT SURG - VOL 38, AUGUST 2012
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CORRESPONDENCE
Table 1. Intraoperative complications in the 2 groups.
Table 2. Complications in the 2 groups 1 day postoperatively.
Number of Cases (%) Complication Buttonholing of scleral flap Intraoperative hyphema Premature entry into AC Iris prolapse Descemet detachment Intraoperative miosis
Group 1
Number of Cases (%)
Group 2 P Value
4 (3.63) 2 (1.81) 5 (4.54) 3 (2.72) 3 (2.72) 2 (1.81) 10 (9.09) 10 (9.09) 1 (0.9) 2 (1.81) 12 (10.9) 4 (3.63) PZ.095 (O.05)
.407 .471 .65 d .56 .039
AC Z anterior chamber
Complication
Group 1
Group 2
Subconjunctival hemorrhage 79 (71.81) 52 (47.27) (red eye) Flap retraction/wound 8 (7.27) 2 (1.21) exposure Hyphema 6 (5.45) 4 (3.63) Iris prolapse 1 (0.9) 2 (1.21) Uveitis R grade 3 7 (6.36) 5 (4.54) (50–100 cells/HPF)
P Value .0001 .026 .517 .806 .552
HPF Z high power field
follow-up. Other postoperative complications were comparable in the 2 groups (Tables 1–3). DISCUSSION Conventional scleral tunnels require preparation of a conjunctival flap. This causes variable bleeding from the conjunctival and episcleral vessels, necessitating cauterization. In developing nations, where a large number of surgeries are performed in eye camps in one sitting, this can cause significant additional expenditures of time, energy, and resources. Self-sealing cataract incisions have been discussed by Colvard et al.,5 Thrasher and Boerner,6 Pallin,7 and Singer.8 Conjunctival flaps were considered a default addition and were considered a necessity by eye surgeons around the world. Conjunctival flaps were advocated in extracapsular cataract extraction (ECCE) because they facilitate a stronger wound closure and also cover any exposed suture knots. The development of clear corneal
Table 3. Complications in the 2 groups 45 days postoperatively.
incisions for phacoemulsification pioneered a new era in which conjunctival flaps had no role. However, no decisive research has been done that justifies or negates the value of a conjunctival flap in manual SICS, which developed as a hybrid of ECCE and phacoemulsification. Manual SICS was shown to be significantly faster than phacoemulsification in a study conducted at the Aravind Eye Hospital,4 but the study did not indicate whether conjunctival flaps were created. In a few of our manual SICS cases, we reduced the surgical time to less than 3 minutes and 30 seconds. If a flap is not created, the conjunctiva remains in its native state and can be used for trabeculectomy blebs if these are required in the future. Not creating a flap may also preserve anterior segment circulation by avoiding excessive cauterization of bleeding vessels associated with flap formation. The conjunctival flap exerts a positive influence in preventing the reopening of the wound in ECCE. However, this step may have been adopted in manual SICS as a default addition by surgeons. We respect the desirability of surgeons for a flap as a prophylactic measure but question it as a necessity.
Number of Cases (%) Complication
Group 1
Group 2
Subconjunctival hemorrhage 9 (8.12) 2 (1.81) (red eye) Iris prolapse 0 1 (0.9) Flap retraction/wound 8 (7.27) 2 (1.81) exposure Uveitis R grade 2 (10–20 2 (1.81) 2 (1.81) cells/HPF) SIA O1.0 D ATR 47 (42.72) 51 (46.36) PZ.2775
P Value .017 .319 .053 d .489
ATR Z against the rule; HPF Z high power field; SIA Z surgically induced astigmatism
REFERENCES 1. Gogate PM, Kulkarni SR, Krishnaiah S, Deshpande RD, Joshi SA, Palimkar A, Deshpande MD. Safety and efficacy of phacoemulsification compared with manual small-incision cataract surgery by a randomized controlled clinical trial; six-week results. Ophthalmology 2005; 112:869–874 2. Gogate P, Deshpande M, Nirmalan PK. Why do phacoemulsification? Manual small-incision cataract surgery is almost as effective, but less expensive. Ophthalmology 2007; 114: 965–968 3. Ruit S, Tabin GC, Chang D, Bajracharya L, Kline DC, Richheimer W, Shrestha M, Paudyal G. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol 2007; 143:32–38
J CATARACT REFRACT SURG - VOL 38, AUGUST 2012
CORRESPONDENCE
4. Venkatesh R, Muralikrishnan R, Balent LC, Prakash SK, Prajna NV. Outcomes of high volume cataract surgeries in a developing country. Br J Ophthalmol 2005; 89:1079–1083. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 1772816/pdf/bjo08901079.pdf. Accessed April 24, 2012 5. Colvard DM, Kratz RP, Mazzocco TR, Davidson B. Clinical evaluation of the Terry surgical keratometer. Am Intra-Ocular Implant Soc J 1980; 6:249–251
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6. Thrasher BH, Boerner CF. Control of astigmatism by wound placement. Am Intra-Ocular Implant Soc J 1984; 10:176–179 7. Pallin SL. Chevron sutureless closure; a preliminary report. J Cataract Refract Surg 1991; 17:706–709 8. Singer JA. Frown incision for minimizing induced astigmatism after small incision cataract surgery with rigid optic intraocular lens implantation. J Cataract Refract Surg 1991; 17: 677–688
J CATARACT REFRACT SURG - VOL 38, AUGUST 2012
3. Jin GJC, Crandall AS, Jones JJ. Intraocular lens exchange due to incorrect lens power. Ophthalmology 2007; 114:417–424 4. Porter J. Incorrect IOL selection [letter]. Ophthalmology 2006; 113:883 5. Burks R. How can this happen? [letter] Ophthalmology 2005; 112:2057 6. Saufl NM. Universal protocol for preventing wrong site, wrong procedure. J Perianesth Nurs 2004; 19:348–351 7. Kohnen S. Postoperative refractive error resulting from incorrectly labeled intraocular lens power. J Cataract Refract Surg 2000; 26:777–778
OTHER CITED MATERIAL A. Hong Kong Hospital Authority. HA Convention 2008 – A New Era of Patient Care, 2008. Available at: http://www.ha.org.hk/haho/ ho/pad/080505-HA-Eng.pdf. Accessed April 6, 2012
Necessity of conjunctival flap in manual sutureless small-incision cataract surgery Punitkumar Singh, MS, Subhadra Singh, MS, Gajesh Bhargav, MS, Manju Singh, MS Online Video High-volume phacoemulsification is difficult in developing countries because the technology requires costly machinery and consumables. Manual smallincision cataract surgery (SICS) is comparable to phacoemulsification in achieving excellent visual outcomes with low complication rates and is significantly faster and less expensive.1–4 The basis of manual SICS is the tunnel construction. By convention, a fornixbased conjunctival flap is considered a requirement. PATIENTS AND METHODS Two hundred twenty eyes of 190 patients having manual SICS were randomized into 2 groups. Group 1 (110 eyes) had manual SICS without a conjunctival flap, and Group 2 (110 eyes) had manual SICS with a fornix-based
1501
conjunctival flap. The intraoperative complications, surgical time, and findings immediately postoperatively and at 45 days and 3 and 6 months were noted and compared using the 2-sample t test between percentages.
Technique in Group 1 A number 11 blade on a Bard-Parker handle (American Ophthalmic Laboratories LLC) was used to make the incision groove directly through the conjunctiva, Tenon, and sclera up to one-third to one-half the scleral thickness, 2.0 to 3.0 mm behind the corneoscleral limbus (Figure 1; Video, available at http://jcrsjournal.org). Cautery was not used and any bleeding was washed away with continuous irrigation. The pocket tunnel was dissected. After routine manual SICS, subconjunctival amikacin and dexamethasone were injected above and below the incision/groove to cause adequate conjunctival ballooning.
Technique in Group 2 A fornix-based conjunctival flap was created starting from the limbus, and electric bipolar cautery was done. At the end of the procedure, the conjunctival flap was reapproximated at the limbus with bipolar cautery.
RESULTS The surgical time was markedly less in Group 1 (mean 7.67 minutes G 1.45 [SD]) than in Group 2 (mean 11.46 G 1.69 minutes) using the independent groups t test between means (P!.001). Intraoperative pupillary miosis was significantly greater in Group 1 (PZ.039). There were more patients with a subconjunctival bleed involving more than 1 quadrant of the bulbar conjunctiva on the first postoperative day in Group 1 than in Group 2, and the difference was statistically significant (P!.0001). Reassurance was all that was required in most cases. Postoperative conjunctival retraction and consequent wound exposure were also significantly higher in Group 1 (PZ.026), but neither endophthalmitis nor infectious iritis was noted in any case on
Figure 1. A: Number 11 blade on a Bard-Parker handle is used to create a groove directly through the conjunctiva and Tenon into the sclera. B: As the groove is formed, the conjunctiva may retract above and below the wound to give a clearer view of the scleral groove. C: A scleral tunnel is formed under the conjunctiva using a disposable metal crescent. J CATARACT REFRACT SURG - VOL 38, AUGUST 2012
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CORRESPONDENCE
Table 1. Intraoperative complications in the 2 groups.
Table 2. Complications in the 2 groups 1 day postoperatively.
Number of Cases (%) Complication Buttonholing of scleral flap Intraoperative hyphema Premature entry into AC Iris prolapse Descemet detachment Intraoperative miosis
Group 1
Number of Cases (%)
Group 2 P Value
4 (3.63) 2 (1.81) 5 (4.54) 3 (2.72) 3 (2.72) 2 (1.81) 10 (9.09) 10 (9.09) 1 (0.9) 2 (1.81) 12 (10.9) 4 (3.63) PZ.095 (O.05)
.407 .471 .65 d .56 .039
AC Z anterior chamber
Complication
Group 1
Group 2
Subconjunctival hemorrhage 79 (71.81) 52 (47.27) (red eye) Flap retraction/wound 8 (7.27) 2 (1.21) exposure Hyphema 6 (5.45) 4 (3.63) Iris prolapse 1 (0.9) 2 (1.21) Uveitis R grade 3 7 (6.36) 5 (4.54) (50–100 cells/HPF)
P Value .0001 .026 .517 .806 .552
HPF Z high power field
follow-up. Other postoperative complications were comparable in the 2 groups (Tables 1–3). DISCUSSION Conventional scleral tunnels require preparation of a conjunctival flap. This causes variable bleeding from the conjunctival and episcleral vessels, necessitating cauterization. In developing nations, where a large number of surgeries are performed in eye camps in one sitting, this can cause significant additional expenditures of time, energy, and resources. Self-sealing cataract incisions have been discussed by Colvard et al.,5 Thrasher and Boerner,6 Pallin,7 and Singer.8 Conjunctival flaps were considered a default addition and were considered a necessity by eye surgeons around the world. Conjunctival flaps were advocated in extracapsular cataract extraction (ECCE) because they facilitate a stronger wound closure and also cover any exposed suture knots. The development of clear corneal
Table 3. Complications in the 2 groups 45 days postoperatively.
incisions for phacoemulsification pioneered a new era in which conjunctival flaps had no role. However, no decisive research has been done that justifies or negates the value of a conjunctival flap in manual SICS, which developed as a hybrid of ECCE and phacoemulsification. Manual SICS was shown to be significantly faster than phacoemulsification in a study conducted at the Aravind Eye Hospital,4 but the study did not indicate whether conjunctival flaps were created. In a few of our manual SICS cases, we reduced the surgical time to less than 3 minutes and 30 seconds. If a flap is not created, the conjunctiva remains in its native state and can be used for trabeculectomy blebs if these are required in the future. Not creating a flap may also preserve anterior segment circulation by avoiding excessive cauterization of bleeding vessels associated with flap formation. The conjunctival flap exerts a positive influence in preventing the reopening of the wound in ECCE. However, this step may have been adopted in manual SICS as a default addition by surgeons. We respect the desirability of surgeons for a flap as a prophylactic measure but question it as a necessity.
Number of Cases (%) Complication
Group 1
Group 2
Subconjunctival hemorrhage 9 (8.12) 2 (1.81) (red eye) Iris prolapse 0 1 (0.9) Flap retraction/wound 8 (7.27) 2 (1.81) exposure Uveitis R grade 2 (10–20 2 (1.81) 2 (1.81) cells/HPF) SIA O1.0 D ATR 47 (42.72) 51 (46.36) PZ.2775
P Value .017 .319 .053 d .489
ATR Z against the rule; HPF Z high power field; SIA Z surgically induced astigmatism
REFERENCES 1. Gogate PM, Kulkarni SR, Krishnaiah S, Deshpande RD, Joshi SA, Palimkar A, Deshpande MD. Safety and efficacy of phacoemulsification compared with manual small-incision cataract surgery by a randomized controlled clinical trial; six-week results. Ophthalmology 2005; 112:869–874 2. Gogate P, Deshpande M, Nirmalan PK. Why do phacoemulsification? Manual small-incision cataract surgery is almost as effective, but less expensive. Ophthalmology 2007; 114: 965–968 3. Ruit S, Tabin GC, Chang D, Bajracharya L, Kline DC, Richheimer W, Shrestha M, Paudyal G. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol 2007; 143:32–38
J CATARACT REFRACT SURG - VOL 38, AUGUST 2012
CORRESPONDENCE
4. Venkatesh R, Muralikrishnan R, Balent LC, Prakash SK, Prajna NV. Outcomes of high volume cataract surgeries in a developing country. Br J Ophthalmol 2005; 89:1079–1083. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 1772816/pdf/bjo08901079.pdf. Accessed April 24, 2012 5. Colvard DM, Kratz RP, Mazzocco TR, Davidson B. Clinical evaluation of the Terry surgical keratometer. Am Intra-Ocular Implant Soc J 1980; 6:249–251
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6. Thrasher BH, Boerner CF. Control of astigmatism by wound placement. Am Intra-Ocular Implant Soc J 1984; 10:176–179 7. Pallin SL. Chevron sutureless closure; a preliminary report. J Cataract Refract Surg 1991; 17:706–709 8. Singer JA. Frown incision for minimizing induced astigmatism after small incision cataract surgery with rigid optic intraocular lens implantation. J Cataract Refract Surg 1991; 17: 677–688
J CATARACT REFRACT SURG - VOL 38, AUGUST 2012