|Year : 1966 | Volume
| Issue : 1 | Page : 31-35
Cataract and iridencleisis-one stage operation
PN Nagpaul, Hari Charan, RP Sarda
Department of Ophthalmology, S.M.S. Medical College & Hospital, Jaipur, India
|Date of Web Publication||12-Jan-2008|
P N Nagpaul
Department of Ophthalmology, S.M.S. Medical College & Hospital, Jaipur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nagpaul P N, Charan H, Sarda R P. Cataract and iridencleisis-one stage operation. Indian J Ophthalmol 1966;14:31-5
|How to cite this URL:|
Nagpaul P N, Charan H, Sarda R P. Cataract and iridencleisis-one stage operation. Indian J Ophthalmol [serial online] 1966 [cited 2019 Jun 27];14:31-5. Available from: http://www.ijo.in/text.asp?1966/14/1/31/38562
The ophthalmologist is often faced with the problem of cataract and glaucoma being present simultaneously in the same patient. This may be a mere coincidence or one may be the cause of the other. The simultaneous presence of the two conditions present is a ticklish problem for the ophthalmic surgeon.
There is considerable diversity of opinion regarding the management of such cases. Broadly speaking, an ophthalmologist has a choice of 3 procedures.
1. To carry out an operative procedure for glaucoma first and follow it up 6 to 12 weeks later by a cataract extraction.
This line of action demands two operative procedures with greater stress on the patient's mind and a longer stay at the hospital, which involves an economic burden in a poor country. Besides this, the idea of 2 operations on each eye when recommended tends to make these elderly patients resign themselves to varying degrees of blindness, rather than submit to frequent ocular surgery.
This two stage procedure may be carried out by making the cataract incision through the bleb; through the cornea anterior to the bleb or through the latero-inferior part of limbus. The section through the bleb is inadvisable unless the ocular tension is 10 mm. or less (Callahan, 1956), otherwise there is postoperative rise of tension above the normal level. The section in the cornea anterior to the bleb makes an intracapsular extraction of the lens difficult owing to the overhanging corneal shelf, However the ocular pressure does not rise postoperatively.
2. To carry out an operative procedure for cataract first and follow it up later by an operation for glaucoma, after 12 weeks.
Besides the disadvantages of having two operations, this has the added disadvantage that aphakic glaucoma is very difficult to treat. Cyclodialysis and cyclodiathermy can lower the ocular pressure only by 6-10 mm of Hg. which may not be adequate.
3. To carry out a one stage operation for cataract and glaucoma. Various techniques are used for this purpose:
(a) Birge (1953) has described the technique of iridencleisis with cataract extraction through the same incision.
(b) McLean (1952) prefers trephining together with cataract extraction.
(c) Callahan (1956) substitutes anterior sclerectomy instead, with cataract extraction.
Wright (1937); O'Brien (1944). Mc-Millan (1950); and Hughes (1959, 1963) recommend the procedure of combining the operations for cataract and glaucoma. However Kirby (1948) opines that a filtering operation simultaneous with cataract extraction is more liable to delay the reformation of anterior chamber which may promote the occurence of peripheral anterior synechiae.
| Material and Methods|| |
50 cases of cataract with glaucoma have been studied. Initially only those cases in which neglected glaucoma had resulted in total or nearly total loss of vision were chosen, to ensure that no adverse complication occured during or following the operative procedure. Most of them from rural areas were unaware of their glaucoma which was detected incidentally when they came for cataract.
These cases can be split up as follows:
1. Glaucoma secondary to intumescens of lens in which the acute or subacute attack had persisted for 72 hours or more and in whom iridectomy alone would be unable to control ocular tension, owing to the peripheral synaechia, necessitating a drainage operation.
2. Chronic simple glaucoma associated with mature or immature cataract.
| Pre-operative Preparation|| |
After routine investigations, it was our aim to reduce the tension as much as possible, by giving miotics or Acetazolamide. Some patients were not adequately controlled on this regime and were given 50% glycerol in normal saline, 1.5 gm/kgm body weight, twice daily. The ocular tension was recorded twice a day. On the day of operation, the dose of glycerol was given two hours pre-operatively.
| Operation|| |
All the cases were operated under local anaesthesia.
Unlike the procedure recommended by most ophthalmologists in which the same incision is used for iridenceleisis and cataract extraction (Birge, 1953) we use separate incisions. The advantage of the separate incisions is, we feel, that the anterior chamber gets well formed within 24 hours in most of our cases.
A groove is made on the cornea splitting upto one third to one-half thickness of the substantia propria near the limbus at 12 O'clock position, 3 mm. in length, along the limbus. An end to end suture is then passed, of which a loop is made and kept aside [Figure - 1]. At 12 O'clock position 6 mm. away from limbus a conjunctional flap is reflected as for iridencleisis [Figure - 2]. After cauterising the bleeding vessels, a keratome incision is made and an iridencleisis performed [Figure - 3]. A continuous conjunctival suture is then applied [Figure - 4]. Before tightening this suture air is injected into the anterior chamber. This cameral introduction of air serves to reform the collapsed anterior chamber and thus make the incision for cataract with a knife safe. Also the injecting of air in anterior chainber stops oozing of blood from the cut iris into the anterior chamber.
A cataract knife is introduced at the limbus between 9 O'clock and 3 O'clock positions and the section is completed through the preplaced corneni groove [Figure - 5]. The lens is extracted in the usual way. If the capsule bursts during extraction the remnants of lens and capsule are removed either by irrigating the anterior chamber or by wiping gently with flattened swabs after lifting the corneal flap.
The preplaced corneal suture is then tied [Figure - 6] and air is injected in the anterior chamber. Subconjunctival pencillin injection is then given and atropine drops instilled. Both eyes are then padded and bandaged.
| Observations & Discussion|| |
The results of 50 cases have been tabulated. The over all postoperative reaction in these cases was in the first few postoperative days a little more than in cases of cataract extracton or iridencleisis alone, but it soon settled down.
The following complications were noted during operation.
1. Extra capsular extraction - An Intra-capsular extraction was attempted in all the fifty cases reported, using Smith's tumbling method, intracapsular forceps or erisophake, depending upon the case, as in routine cataract surgery. However in 14 cases the lens capsule gave way and an extracapsular lens extraction resulted. This incidence is higher than what the authors experience in their routine cataract surgery, and could be a result of either touching of the lens whilst making the section for cataract in an eye with a shallow anterior chamber and low tension or because of the corneal ledge which makes an intracapsular extraction relatively more difficult.
2. Vitreous Escape - out of 50 cases operated upon 7 cases had vitreous escape that is in 14% of cases. Arruga (1956) considers that vitreous escape in simple cataract extraction is 2 to 5%. Considering the fact that all these patients had an initial raised tension and some of them even had tension higher than normal at the time of operation, the incidence of vitreous loss is not high.
3. Hyphama - In five, out of the fifty cases, there was hyphaema following iridencleisis extraction. This hyphaema, is not considered to be of any importance in a case of iridencleisis, but it obstructs the view and makes the operation more difficult, when this procedure is followed by cataract extraction.
4. Sutures - Out of the fifty cases, in three cases the preplaced suture got cut at the time of making the section and in two of the cases the preplaced suture cut away through the edge of the wound because of a shallow bite of corneal thickness. These faults in technique occured only in the first 25 cases.
5. Involuntary Iridectomy-In three of the cases iris was cut involuntarily whilst making a cataract section. This was on account of the shallow anterior chamber and low tension. Injection of air through the clean iridencleisis incision prior to cataract section minimised the chances of such a difficulty arising.
6 Buttonholing of the conjunctiva-Occured in one case whilst reflecting conjunctiva for iridencleisis. It was dealt with in the usual manner.
7. Iridodialysis occured in one case whilst performing iridencleisis. It was because the iris tissue got caught in the teeth of the iris forceps while withdrawing the forceps.
The following complications were noted post-operatively.
1. Keratitis: This was the commonest postoperative complication occuring in 27 out of 50 cases. The severity varied chiefly and was usually of a mild nature. Thus in 13 cases it lasted for 3 days or less and in 11 cases upto 6 days. Only in 3 cases it persisted for more than 9 days.
2. Shallow Anterior Chamber: Although in 6 of the cases reported, there was a persistent shallow anterior chamber which lasted from 3 to 6 days, the shallowness of the chamber did not appear to influence the ultimate result.
3. Hyphaema: Five out of the 50 cases suffered from hyphaema during its post-operative course. In three of the five cases paracentesis and irrigation of the anterior chamber had to be performed because the medical treatment had failed.
4. Iris Incarceration: In one case the iris tissue got incarcerated in the corneal section made for lens extraction. Since there was no prolapse surgical treatment was not required.
The improvement in visual acuity was what would be expected after a cataract extraction, bearing in mind that considerable visual damage can be caused by the glaucoma in such cases.
Of the 50 cases reported [Table - 1] 6 cases did not attend for follow up on being discharged from the hospital whilst 6 cases only came for check tip after three months of operation. Since a true long term picture regarding the state of ocular tension is not depicted by these 12 cases they have been excluded for the purposes of assessing the effect in intraocular pressure. Of the remaining 38 cases, in 32 cases (82.2%) the intraocular pressure was within normal limits without any adjunctive treatment. In 6 cases (15.8%) the intraocular pressure was raised. They were put on miotic therapy which was effective in only one case. The remaining five cases were advised a cyclodialysis operation. Three more cases, in whom the ocular tension was on the high normal side were advised miotics as a precautionary measure.
Tensions at the end of 1 year were invariably higher than at the time of discharge but were within normal limits.
| Summary|| |
50 cases of cataract associated with various types of glaucoma have been surgically treated by a one stage operation. In this technique a separate incision is made to receive and lock the iris, which is made previous to and above the incision for cataract extraction. Ocular tension was normalised without further miotic therapy in 84.2% of cases.
| References|| |
Birge, II. L.: (1953) Amer. J. Ophthal. 36, 925.
Callahan, A.: (1956) "Surgery of the eye - Diseases" p. 287. Charles C. Thomas Publishers U.S.A.
Guyton, J. S.: (1945) AMA. Arch. Ophthal. 33, 265.
Hughes, W. L.: (1959) Amer. J. Ophthal. 48, part I., 1.
Hughes, W. L. et al: (1963) Amer. J. Ophthal. 56, 391.
Kirby, D. B.: (1949) "Surgery of Glaucoma." Postgraduate Lectures on Ophthalmology, State University of Iowa Hospital June 14-19, 1949.
Knapp, A.: (1947) Arch. Ophth., 38, 1.
Lee, O. S. and Weih, J. E.: (1950) Arch. Ophth., 44, 275.
MacLean, A. L.: (1962) Tr. Am. Ophth. Soc. 50, 136.
MacMillan, J. A., (1950) Arch. Ophth., 43, 195.
O'BRIEN C. S.: (1944) Quart. Bull. North Western Univ. M. School, 18, 199.
Suen Larsen: (1953) Br. J. Ophthal. 37, 257.
Tamler, E and Maunmenee: (1955) A.M.A. Arch. Ophthal. 54, 816.
Wright, R. E. (1937) Amer. J. Ophth., 20, 376.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1]