|Year : 1988 | Volume
| Issue : 1 | Page : 12-14
Pars plana or anterior lensectomy for traumatic cataracts?
HK Tewari, R Sihota, N Verma, Rajvardhan Azad, PK Khosla
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India
H K Tewari
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029
Source of Support: None, Conflict of Interest: None
Traumatic cataracts can nor be adequately managed with cutting aspiration systems by an anterior or pars planes approach 20 cases were randomly assured to these two approaches Pars plana lensectomy caused a more frequent uveitis and secondary glaucoma, though the visual acuity achieved post-operatively was similar in the two groups. We recommend an anterior lensectomy for patients who do not require simultaneous posterior segment surgery, because the retained posterior capsule decreases the indicence of complications.
Keywords: Traumatic cataracts- cutting aspiration systems - best approach - anterior lensectomy - absent posterior pathology
|How to cite this article:|
Tewari H K, Sihota R, Verma N, Azad R, Khosla P K. Pars plana or anterior lensectomy for traumatic cataracts?. Indian J Ophthalmol 1988;36:12-4
|How to cite this URL:|
Tewari H K, Sihota R, Verma N, Azad R, Khosla P K. Pars plana or anterior lensectomy for traumatic cataracts?. Indian J Ophthalmol [serial online] 1988 [cited 2019 Dec 6];36:12-4. Available from: http://www.ijo.in/text.asp?1988/36/1/12/26172
| Introduction|| |
The introduction of the roto extractor highlighted the suitability of cutting- aspiration systems for congenital and juvenile cataract surgery, and most especially for traumatic cataract surgery. The pars plana use of these instruments has achieved great popularity of late, despite the inherent disadvantage of the associated vitreous manipulation which is thought to increase the incidence of cystoid macular edema and retinal detachments
In 1982 the classical anterior discission- aspiration was compared to a Pars plana lensectomy, and superior visual results were achieved in the former . We carried out this study hoping to combine the advantages of the anterior route, with the fineness of cutting-aspiration microsurgery. We have compared anterior route lensectomies, to an equal number of pars plana lensectomies.
| Patients and Methods|| |
20 consecutive cases having traumatic cataracts and an ultrasonographically quiet posterior segment were included in this study. All patients had fresh injuries with a clear central corneal area Plain skiagrams of the orbit were done to rule out a radio- opaque foreign body and contact A and B mode ultrasonography was performed over the closed lid with the Ocuscan 400 (Sonometrics) for posterior segment evaluation. The patients underwent a complete systemic and ocular examination. All surgery was performed under general anaesthesia, using a Zeiss Op Mi 6 operating microscope, by two of the authors (HKT and RS).
The age of the patients, ranged from 4-30 years 17 patients suffered a penetrating ocular injury, 8 caused by wooden sticks, 4 due to glass pieces, 2 by a thorn prick, and one each by a metallic rod metallic wire and a sewing needle Three patients had contusion injuries, one due to a blast of compressed air and the other two injury with a " gulli" (a type of wooden bale used in a game in India).
In all cases the comeal/corneoscleral wound, if present was sutured, with an additional uveal abscission or reposition as required. The cases were alternately assigned to the pars plana and anterior lensectomy groups.
Best corrected visual acuity assessment and a thorough slit lamp examination were recorded at 1 week, 6 weeks and 1 year post surgery. After dilatation of the pupil, a fluorescein angiogram was done at 6 weeks and 1 year post- operatively to evaluate the posterior pole for cystoid macular edema and at the same sitting. the peripheral fundus was examined, using an indirect ophthalmoscope.
Pars plana lensectomy was performed as classically described and an anterior vitrectomy was also performed. Iris adhesions and synechiae were concomitantly dealt with The probe was slowly withdrawn allowing reformation of the anterior chamber with the infusion fluid (Ringer lactate solution with 0.8/ ug of gentamycin/mL). Decadron phosphate (1 mg), gentamycin (10 mg) and mydricaine (0.2'cc) were injected subconjunctivally.
For the anterior route lensectomy, maximal preoperative dialatation of the pupil was achieved by a subconjunctival injection of mydricaine, and a 4 mm long,, posterior limbal incision was made. A Bowman s needle was introduced to enter the lens capsule. All the lens matter, together with as much of the anterior capsule as possible was removed and the posterior capsule was completely cleared and polished.
Routine postoperative care with antibiotic and corticosteroid drops and ointment was used for 4 weeks Aphakic correction in all cases was achieved with either soft or hard contact lenses The follow-up period ranged from 12-15 months
| Results|| |
Postoperative examination of the patients [Table - 1] after one week revealed a higher incidence of striate keratopathy and corneal edema in those who underwent anterior route surgery. The anterior vitreous was examined on the slit lamp showing that vitreitis was significantly more common in patients of the pars plana group (p < 0.01) A secondary glaucoma with the highest intraocular pressure ranging from 26-34 mmHg was also seen in this group. There was no significant difference in the occurrence of iridocyclitis or the best corrected acuity achieved in the two groups, at this time..
Six weeks after surgery, striate keratopathy was present near the limbal wound of one patient from the anterior route group in whom the surgical time was prolonged to one hour because of a malfunctioning probe. A patient in this group was also noted to have an irregularly pigmented appearance of the macula, and a vision of 6/24. An intraocular pressure of 28 mmHg persisted in a patient who had a severe vitritis, due to the presence of lens matter in the posterior vitreous, following pars plana lensectomy. This patient was the only one noted to have cystoid macular edema and a vision of 6/24 at the first examination after surgery.
Examination after one year, showed a persistence of the cystoid macular edema in this patient who could only read 6/18 on the Snelleri s chart The patient with least visual acuity from the anterior route group, had pigmentation and achieved a vision of 6/3 6. There was thus a vision of 6/9 or better in 9 patients of each group [Table - 2].
Examination of the peripheral fundus was recorded at the end of one year [Table - 3] as all the patients were not cooperative and could not be examined at 6 weeks. 'While without pressure' was seen in three patients who had a pars plana lensectomy and in 2 after an anterior approach This was related to the area of the pars plana wound in two of the patients seen. Scattered peripheral pigmentation was present in 4 patients of the pars plana group and 2 after an anterior lensectomy. This was denser inferiorly. Lattice degeneration of 1 1/2 clock hours was associated with the 'white without pressure ,seen in a patient who underwent an anterior approach lensectomy. No retinal or vitreous traction bands were seen in any patient.
| Discussion|| |
Traumatic cataracts pose a problem to the ophthalmologist both in terms of surgery, as well as subsequent visual recovery. Advances in paediatric anaesthesia, surgical instrumentation, suture materials and operating microscopes, together with the availability of various antibiotics, corticosteroids and hyperosmotic agents have greatly increased the success rate of such operative ventures.
There are almost as many methods of cataract extraction, in the young, as there are surgeons dealing with them Grossly two approaches have been used, the anterior and the pars plana The anterior route is either a 'classical' discussion and aspiration or the more recent use, of a cutting-aspiration system through a limbal approach The pars plana approach is performed with a cutting- aspiration system.
We utilised the developments in irrigation- aspiration cutting systems to extract traumatic cataracts, while preserving the posterior capsule and minimizing manipulation of the vitreous. In the anterior approach, all aspects of the procedure were performed under direct visualization, using the magnification of the operating microscope to allow retention and complete clearing of the posterior capsule'. None of these patients developed a subsequent after cataract We found no prolonged adverse effects on the cornea with the anterior route and we feel that this, supposed, disadvantage should now be discounted
The only serious complications in our study were found in patients having undergone a pars plana lensectomy. The prolonged vitritis and secondary glaucoma noted, could be attributed to the presence of lens matter and free vitreous in the anterior chamber or undetected trauma to either the ciliary body or isis, during surgery.
Traumatic cataracts having some form of posterior segment pathology are probably best treated by pars plana lensectomy with concomitant repair of the posterior abnormalities. However, utrasonography in eyes, having traumatic cataracts, revealed that 45.8%
Traumatic cataracts having some form of posterior segment pathology are probably best treated by pars plana lensectomy with concomitant repair of the posterior abnormalities. However, ultrasonography in eyes, having traumatic cataracts, revealed that 45.8% were within normal limits and 23.6% had a minimal vitreous haemorrhage which did not require specific treatment . Therefore approximately 70% of traumatic cataracts have no absolute indication for the use of the pars plana approach In a study of 36 patients undergoing a pars plans lensectomy, 7 patients patients were found to show serious complications i e. macular pucker and secondary glaucoma post-operatively . Another review, found a markedly increased incidence of cystoid macular edema in eyes having a pars plana lensectomy as compared to those having a classical discussion and aspiration surgery'. This suggests that the anterior route is less traumatic to the eye, in the long term.
On the basis of our work, and the views quoted above, we feel, that patients who do not require simultaneous posterior segment surgery, should undergo an anterior route lensectomy, as the visual results are as good, while the incidence of complications is very much lower.
| References|| |
Hoyt CS, Nickel R Aphakic cystoid macular edema Arch Ophthal 1000: 746-749, 1982.
Girard IJ. Aspiration irrigation of congenital and traumatic cataracts Arch. Ophthal 77: 387-391, 1967.
Kashaloglu M. Echographic findings in eyes with traumatic cataracts Am. J. Ophthal99 : 496-498, 1985.
Bide N, Vatne HO, Sydalen P. Pars plana lensectomy. Acta Ophthal 63 : 250-253, 1985.
[Table - 1], [Table - 2], [Table - 3]