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Year : 2004  |  Volume : 52  |  Issue : 4  |  Page : 311-7

Intraoperative performance and longterm outcome of phacoemulsification in age-related cataract.

Iladevi Cataract & IOL Research Centre, Ahmedabad, India

Date of Submission18-Nov-2003
Date of Acceptance09-Jul-2004

Correspondence Address:
Sheena A Dholakia
Iladevi Cataract & IOL Research Centre, Ahmedabad
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Source of Support: None, Conflict of Interest: None

PMID: 15693323

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PURPOSE: To evaluate intraoperative performance and longterm surgical outcome after phacoemulsification of age-related cataracts. METHODS: Prospective, observational, non-comparative study of 165 consecutive eyes undergoing phacoemulsification with nuclear sclerosis Grade I to III (Scale I to V). Preoperative evaluation included specular microscopy. Phacoemulsification was performed by a single surgeon using a standardised surgical technique under topical anaesthesia. Intraoperatively, effective phaco time (EPT), wound site thermal injury (WSTI), serious complications (eg. vitreous loss, posterior capsule rupture, zonulolysis) and intraoperative posterior capsule opacification (plaque) were evaluated. Postoperatively, posterior capsule opacification (PCO), Neodymium:YAG (Nd:YAG) laser posterior capsulotomy rate, corneal endothelial count, best corrected visual acuity and cystoid macular oedema were evaluated. Eyes were examined at 6 months and then yearly for 3 years. RESULTS: Mean ages of 78 males and 87 females were 59.12 +/- 8.56 and 58.34 +/- 7.45 years respectively. EPT was 36 +/- 19 seconds and WSTI occurred in 7 eyes (4.7%). No serious intraocular complications occurred. Intraoperative posterior capsule opacification (plaque) was present in 21 eyes (13.93%). Postoperatively, PCO occurred in 8 eyes (4.84%) and Nd:YAG laser posterior capsulotomy was performed in 3 eyes (1.8%). Endothelial cell loss was 7.1% at 3 years follow-up. At the end of 3 years follow-up, 146 eyes (88.89%) maintained a best corrected visual acuity of > or = 6/12. Cystoid macular oedema did not occur in any eye at 1 and 6 months' follow-up. CONCLUSION: PCO rates and endothelial cell loss were acceptable. Consistent and reproducible outcome can be obtained after phacoemulsification of age related cataracts (grade I to III).

Keywords: Cataract, phacoemulsification, performance, complications, visual outcome

How to cite this article:
Dholakia SA, Vasavada AR. Intraoperative performance and longterm outcome of phacoemulsification in age-related cataract. Indian J Ophthalmol 2004;52:311

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Dholakia SA, Vasavada AR. Intraoperative performance and longterm outcome of phacoemulsification in age-related cataract. Indian J Ophthalmol [serial online] 2004 [cited 2020 Aug 14];52:311. Available from: http://www.ijo.in/text.asp?2004/52/4/311/14564

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The techniques and results of cataract surgery have changed during the last three decades and phacoemulsification has become the preferred technique. [1],[2],[3]Several studies on the outcome of phacoemulsification have been reported. To our knowledge, intraoperative performance and long-term outcome in age related soft to firm (Grade I-III in a scale of I-V) cataracts has not been documented in Indian eyes.

Therefore we designed the following prospective study, which aims at assessing results of patients with age-related soft to firm cataract undergoing phacoemulsification at our centre.

  Materials and Methods Top

This prospective, observational, non-comparative study comprised 173 consecutive patients above the age of 50 years who met the inclusion criteria. All patients received phacoemulsification between October 1999 and February 2000.

We included cataracts of Grade I-III on scale of I-V [Figure - 1]a,1b,1c. Diabetics and hypertensives were also included. Grade IV and V (brunescent and black), total and traumatic cataracts were excluded. Patients with co-existing ocular disease (eg. glaucoma, iritis), difficult environment (eg. small pupil, pseudoexfoliation), pathological myopia and patients with only one functioning eye were also excluded.

Pre-operative evaluation included slitlamp examination including examination with +90 D, keratometry, A scan biometry and non-contact specular microscopy with Konan SP 8000 noncon ROBO specular microscope (Konan Medical, Inc, Japan) were performed.

The surgical procedures were performed by a single surgeon (ARV), under topical anaesthesia using a standarised technique. After a 3.0 mm temporal clear corneal incision was made, the chamber was refilled with Viscomet ® (Hydroxy propyl methyl cellulose 2%, Milmet, Baroda). Continuous curvilinear capsulorhexis (CCC) was then performed with a 26 G bent cystotome through empty syringe. Cortical - cleaving hydrodissection was done with 27G cannula and rotation was done with iris spatula through a side port. In eyes where rotation was not possible due to cortico-capsular adhesions (CCA), multi-quadrant and/or focal hydrodissection was done at the site of CCA. Central sculpting was done with 25° bent Kelman microtip with 45° bevel. Parameters used with Alcon Legacy 20000TM phacoemulsifier (Fortworth, Texas, USA)were: ultrasound (U/S) energy 50-60%, vacuum 40 mmHg, aspiration flow rate (AFR) 25 cc/min.

In cataracts of grade I, nucleotomy was performed which resulted in two hemi-sections. Each hemi-section was then aspirated at posterior plane. The U/S energy was reduced to 20%, vacuum 150- 250 mm Hg and AFR 20 cc min. In cataracts of grade II and III, the nucleus was chopped by our previously published techniques (step-by-step, chop in-situ and lateral separation).[4] Parameters were U/S energy 40-50%, vacuum 250-400 mm Hg. and AFR 25 cc/min appropriate to the grade of cataract.

Nucleus was divided into multiple small fragments and removed by the chop, chop and stuff technique.[5] As more and more posterior capsule was exposed, vacuum was progressively reduced. Care was taken to perform the entire emulsification and aspiration at the posterior plane. Occurrence of WSTI was noted and subjectively graded as follows: mild - tissue whitening, moderate - tissue pouting and severe - tissue fish-mouthing. In cases where WSTI occurred, the wound was tested for leakage with fluorescent strip.

Cortical clean-up was completed using the straight tip irrigation-aspiration (I/A probe) with a 0.3 mm diameter. Parameters were vacuum of 500+ mm Hg and AFR 25 cc/min. Posterior capsule vacuum polishing was done with vacuum of 5 mm Hg. and AFR 5 cc/min when cortical fibres were found adherent to posterior capsule. The condition of posterior capsule- clear or intraoperative PCO (plaque) was noted. Three-piece Alcon Acrysof MA30BATM IOL (Alcon, Texas,USA) with a 5.5 mm optic and 12.5 mm overall size was implanted in the bag with forceps after the incision was enlarged to 3.5mm.

Residual Viscomet ® was removed with I/A probe from the anterior chamber and also from behind the IOL. This was done for a clock time of 2 minutes.

0.1 ml. / 1.0 mg vancomycin was injected intra-camerally.

Effective phaco time in seconds was calculated as follows:

U.S. time x Average Power


Combination of dexamethasone (0.1%) and neomycin (0.5%) eye drops 4 times a day were prescribed for 1 month and then tapered within 2 weeks. Tropicamide (1%) eye drops were given at bedtime for a week.

Examination of posterior capsule for posterior capsular opacification (PCO) was done at 6 months and then yearly till 3 years [Figure - 2] a-c. Examination was performed under maximum mydriasis. Observations regarding post-operative PCO were made by dividing the posterior capsule into three zones as follows: (1) Peripheral (outside the optic) [Figure - 3]a, (2) Central (behind the optic′s central 3 mm) and (3) Mild-peripheral (the zone between peripheral and central zones) [Figure - 3]b. The opacification was charted out by a method described by us elsewhere.[6] Corneal specular count (CD, CV, 6A) was performed at 6 months, 1 year and 3 years. Best corrected visual acuity (BCVA) was analysed. Eight patients were lost to follow-up due to medical morbidity and death. Hence, we describe results of 165 eyes.

  Results Top

Mean ages of 78 men and 87 women were 59.12 ± 8.56 and 58.34 ± 7.45 years respectively. Mean axial length was 23.44 ± 1.09 mm. Tables 1 and 2 describe morphology of the cataract CCC was achieved in all eyes. Step-by-step chop-in situ and lateral separation and nucleotomy technique were performed in 137 (83%) and 28 (17 %) eyes. Preoperative best corrected visual acuity was < 6/60 in 44 (26.67%) eyes, between 6/60 - 6/18 in 63 (38.18%) eyes, between 6/18 - 6/12 in 49 (29.70%) eyes and between 6/12 - 6/9 in 9 (5.45%) eyes. Effective phaco time (EPT) was 36 ± 19 seconds. Wound site thermal injury (WSTI) occurred in 7 eyes (5.45%) of which 4 (2.42%) were mild and 3 (1.8%) moderate. In all 7 eyes, WSTI occurred during the stage of sculpting. None of the wounds leaked on fluorescent strip testing. Serious intraoperative complications (e.g. posterior capsule rupture, zonular dialysis, vitreous loss) did not occur. Corneal endothelial cell loss and morphology results are stated in Tables 3 and 4 respectively. Intra-operative PCO (plaque) was present in 14 (8.48%) eyes. Post-operative posterior capsule opacification (PCO) development is shown in Table. Nd:YAG laser posterior capsulotomy was performed in 3 eyes (1.8%) during the third year. Nd:YAG laser posterior capsulotomy for intra-operative PCO (plaque) was not required. 146 eyes (88.89%) maintained a BCVA 6/12 at 3 years. 9 eyes (5.45%) had age-related macular degeneration, 4 eyes (2.42%) had myopic degeneration and 6 eyes (3.63%) with diabetic maculopathy achieved BCVA between 6/24 - 6/12. Clinical cystoid macular oedema (CME) did not occur in any eye at 1 month and 6 months.

  Discussion Top

Grade I to III cataracts (on scale I to V)[7] are soft to firm in consistency. We believe that these cataracts are of optimum density for performing phacoemulsification and are amendable to many phacoemulsification techniques. Therefore, we would like to consider these cataracts as ′standard′ and describe their intraoperative performance and long-term outcome. The results of the present study might give beginning and experienced phacoemulsification surgeons′ a basis for comparision of their results.

The age at cataract surgery is usually different in different populations. [8],[9],[10]In our population, cataract seems to be occurring earlier. Also, cataracts are now operated at an earlier stage with advancement in surgical techniques.

Intraoperative Performance

Our phacoemulsification technique ′Step by step chop in situ and lateral separation′ can be used to divide the nucleus with minimal stress to the capsular bag and zonules. We first create a central space and then divide the entire nucleus into small wedge-shaped segments, which are consumed within the central space at the posterior plane. Our technique contributes to successful and safe phacoemulsification. The chop technique is not always applicable to soft cataracts.[11] It is difficult to obtain a vacuum seal and/or hold the nucleus. Performing nucleotomies followed by aspiration is both safe and effective in these cataracts.

The effective phaco time (EPT) of Dr. Akahoshi is less than 10 seconds (Personal Communication). Our EPT of 36 ± 19 seconds may appear higher. Higher phaco energy was required probably because we aimed to perform posterior plane phacoemulsification involving use of less aggressive aspiration parameters. The EPT depends on the density of the cataract. Therefore, in our previous study, the EPT of brunescent and black cataract[12] was 121.2 ± 19.8 and 187.2 ± 94.2 seconds respectively.

Eyes in which wound site thermal injury (WSTI) occurred had grade III cataract. In these cases, WSTI occurred during the stage of sculpting probably due to uninterrupted use of ultrasound energy. In all eyes, EPT was more than average. In our study of brunescent and black cataract,[12] incidence of WSTI was 9.09% and 13.01% respectively. Using ultrasound energy in an interrupted manner and swinging the foot-switch from position 3 to 2 intermittently may have avoided this complication. Also, remaining in footswitch 2 for a longer time before re-entering footswitch 3 may have cooled the incision and prevented WSTI. Once WSTI was, recognised the incision was enlarged to cool the incision by increasing wound leak. In hind sight, incisions were judged to be tight. We recommend slightly larger incisions in cataracts grade 3 and above. A wound burn can cause incomplete wound closure and undesired astigmatism.[13] In the present study, none of the wounds leaked on fluorescent strip testing and did not require suturing. Sugar et al[14] have reported astigmatism of +7 dioptres to +15 dioptres following WSTI. However, in this study, astigmatism of more than 2 dioptres did not occur probably as suturing was not required.

Vitreous loss is one of the most significant complications to affect visual outcome after cataract surgery. It would be as low as 1% and as high as 9.9%.[15],[16] This partly depends on the experience of the surgeon.[17],[18] We attribute the absence of these complications in the present study to the extensive experience of the surgeon.

Even after thorough posterior capsule vacuum cleaning, some capsules are found to have intra-operative PCO (plaque). It is interesting to note that Nd:YAG laser posterior capsulotomy was not performed in any eye for intra-operative PCO (plaque). This is consistent with our earlier observations.[19]

Postoperative Outcome

The incidence of PCO is now rapidly decreasing from rates as high as 50% in the 1980s to early 1990s to single digits with modern surgical techniques.[20] Several surgery related[21] factors have been identified to play a crucial role in preventing or at least delaying PCO. Apple et al[21] report that thorough cortical clean-up delays the onset of PCO. This can be accomplished by multi-quadrant hydrodissection.[22]

IOL choice has also been reported to influence rate of PCO. [23],[24],[25]Several studies report that the rate of PCO is lower with AcrySof ® IOL.[26],[27] In the present study, although all patients developed peripheral PCO and many patients developed mid-peripheral PCO, the incidence of central PCO was less. We attribute the low PCO rate in this study to thorough cortical clean-up and AcrySof ® IOL. Also, the present study excluded patients with associated diseases like glaucoma, pseudoexfoliation, and iritis that result in greater PCO. Although 3 years is a reasonably long period to observe the PCO development, a still longer follow-up could be more conclusive. Nd:YAG rates ranging from 0% to 6.2% [28],[29],[30],[31] is reported after phacoemulsification and implantation of AcrySof ® IOL over a follow-up of 1 year to 3 years. The Nd:YAG rate of 1.8% in the present study compares favourably with the literature reports.

After phacoemulsification, Kiss et al[32] report endothelial cell loss of 0.3% at 3 months′ follow-up. Kosrirukvongs et al[18] found endothelial cell loss 23.2% with chip and flip technique at 3 months′ follow-up. Recent advances in endocapsular phacoemulsification procedures, instruments, IOLs and viscoelastics appear to have helped decrease the degree of endothelial damage. Hayashi and co-authors[33] have identified several risk factors including grade of nucleus and old age for endothelial cell loss. Our study results agree as we have previously reported that the endothelial cell loss after phacoemulsification of brunescent and black cataract at 1 year was 13.05% and 15% respectively.[14] A lower endothelial cell loss of 5.9% was noted following phacoemulsification in individuals below 50 years with softer cataracts (Forthcoming, J cataract Ref Surg).

Lesiewska et al[34] report that increased cell loss is observed 2 years after phacoemulsificaiton and it matches with the physiological cell loss after 5 years. The present study results agree as after 3 years of phacoemulsification, the cell loss was higher than the physiological rate. Kosrirukvongs et al[18] found endothelial cell loss to be dependent on the phacoemulsification technique: 9.9% with divide and conquer and 23.2% with chip and flip at 3 months follow-up. We speculate that since we adhered to phacoemulsification at the posterior plane with both the techniques the endothelial cell loss was lower. The cell loss could have been further minimised by using viscoelastics like Sodium hyaluronate 1% (Healon ®) and Sodium hyaluronate 3%-chondroitin sulphate 4% (Viscoat ®) and BSS plus ®.

Good visual recovery is reported with use of Acrysof ® and MemoryLens as compared to PMMA and silicone lenses at 3 years follow-up.[26],[35] In the present study, patients without retinal pathology obtained good vision.

It is possible that we could have missed cases of cystoid macular oedema (CME) as we did not perform fundus flourescein angiography. Ursell et al[36] report a 19% angiographic CME although clinical CME was not seen in any of their patients after phacoemulsification.

In summary, consistent and reproducible outcome can be obtained after phacoemulsification in Indian population.

  References Top

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  [Figure - 1], [Figure - 2], [Figure - 3]

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

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