|Year : 1991 | Volume
| Issue : 2 | Page : 53-54
Why go endocapsular?
Manoj R Mehta, Vijay K Dada, Anuj K Singh
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, New Delhi-110 029, India
Manoj R Mehta
H/67-d, Saket, New Delhi 110 017
Source of Support: None, Conflict of Interest: None
A prospective randomized clinical trial was carried out to compare the intercapsular or the endocapsular technique of IOL insertion and conventional posterior chamber IOL insertion after can opener capsulotomy. Age and sex matched groups of 76 patients each underwent surgery by the two techniques. The corneal and the uveal reaction was evaluated on the first day after the surgery and specular counts were done at six weeks. Though the difference between the two groups was not statistically significant, a trend in favour of intercapsular technique emerged strongly.
Keywords: Endocapsular, Can Opener
|How to cite this article:|
Mehta MR, Dada VK, Singh AK. Why go endocapsular?. Indian J Ophthalmol 1991;39:53-4
| Introduction|| |
Introduction of a secondary posterior chamber implant by Harold Ridely in 1949 has proved to be a turning point in the optical rehabilitation after cataract surgery. An entirely new vista of possibilities has opened to the ophthalmologist. This has resulted in a multitude of lens designs, materials, surgical techniques and place of fixation of IOLs.
The aim of a surgical technique is to produce minimal trauma to the delicate ocular tissues, thus avoiding immediate and delayed blinding complications. Intercapsular or endocapsular technique as described initially by Baikoff' is a step towards this goal. This procedure has been projected to have several theoretical advantages.
1. Protection of endothelium at the following stages of surgery.
(a) nucleus delivery
(b) during anterior chamber wash (turbulence keratopathy)
(c) during insertion of an IOL
2. 100% in the bag placement of the lower haptic in the case of a J.or C loop lens.
3. Decreased ciliary body irritation. In order to substantiate the claims made by the proponents we designed a prospective double blind clinical trial to compare endocapsular technique with the conventional can opener capsulotomy technique.
| Material and methods|| |
The patients admitted to the wards of our centre were randomly divided into two groups after age and sex matching. 76 patients underwent capsulotomy by the can opener technique and insertion of a modified J loop IOL while
another 76 underwent an intercapsular technique given in detail below. Specular counts were done preoperatively and eyes with good count and morphology only were inducted in the study. Ringer lactate solution was used for irrigation.
| Intercapsular technique|| |
A linear capsular incision was made connecting small cuts with a 26 gauge capsulotomy needle along the 10' to 2 '0 clock meridians. The bent capsulotomy needle was inserted below the anterior capsule and about 0.5 cc of Ringer lactate was injected subcapsularly for hydrodissection of the nucleus. The nucleus was delivered using an irrigating vectis and a lens hook. A Daljit cannula was used to aspirate the residual cortical matter. The capsular bag was inflated using 2% methyl cellulose and the lower haptic of the IOL guided into it under an iris repositor. The upper loop was tucked below the visible upper flap of the capsule.
The lens was then dialed to get the upper loop inside the bag. The capsulotomy was extended by a vertical cut with Vanna's scissors. The lower edge of the flap was then torn in a rotary motion with the help of a McPhersen's forceps. Completion of the capsulectomy was followed by pupillary constriction.
The surgeries were performed by the same surgeon having proficiency in both the techniques. The cases were followed up and the corneal as well as the iris reaction were noted. In the post operative period the reaction was graded from + to ++++ for uveitis and corneal decompensation. A specular endothelial count was carried out 6 weeks post operatively.
| Results|| |
The results are summarized in [Table - 1]. There was no statistically significant difference in the postoperative uveitis, corneal decompensation or endothelial cell loss between the endocapsular group and the can opener group. However the results are suggestive of a trend in favour of the endocapsular surgery. Severe degrees of iridocyclitis as well as corneal oedema were seen in a relatively low percentage of cases undergoing intercapsular surgery.
| Discussion|| |
The endocapsular fixation of an IOL and the surgical procedure have several advantages which became apparent during the course of our study.
A. Intra Operative Advantages
1. Smaller and predictable, more controlled capsulotomy.
2. The same capsulotomy technique cam be utilized for all types of cataract.
3. Hydrodissection of the nucleus can be carried out safely under the capsular flap. It makes the delivery of the nucleus easy.
4. Endothelium is protected during the nucleus delivery.
5. Endothelium is protected during aspiration of the cortical matter because of decreased turbulence.
6. Iris entanglement in the port and subsequent iris transillumination syndrome is reduced.
7. Smaller quantity of viscoelactic substance are required to inflate the capsular bag.
8. 100% capsular fixation of the lower loop under direct vision.
9. IOL does not touch the iris or the endothelium during insertion.
10. A better centering of the implant can be achieved.
11. In case of rupture of the posterior capsule the anterior flap can provide support for a sulcus supported lens.
12. Useful technique when there are posterior synechiae.
13. Surgery can proceed after zonular dehiscence also. The bag can be inflated again with viscoelastic material.
B Post Operative Period
1. Reduced corneal damage causes less oedema.
2. Reduced iridocyclitis.
3. Reduced incidence of cystoid macular oedema.
4. Sunset/Sunrise syndromes occur infrequently.
A few earlier studies have favoured the intercapsular technique. The results of our study indicate a trend favouring intercapsular technique though the difference is not statistically significant from the conventional technique.
Distortion of the upper flap during the delivery of the nucleus, tearing of the anterior capsular flap or irregular tears during the process can severely jeopardise the surgical outcome. The technique is only slightly more difficult than conventional surgery but is likely to produce better results. It is safar to switch over to the intercapsular surgery.
| References|| |
Baikoff G Insertion of the Simcoe Posterior chamber lens into the capsular hag. An Intraocular Implant. Soc.J.1981. 7:267-269.
Galand A: A simple method of implantation within the capsular bag. Am Intraocular Implant Soc. J, 1983, 9 330-332.
Fernandez S Tony. Pious Sebastian and Moniz Noel. Endocapsular Insertion of Intraocular Implant. Ind. J. Ophthal . Vol.37. No.2. April June. 1989, 75-77.
[Table - 1]