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| EDITORIAL |
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| Year : 1999 | Volume
: 47
| Issue : 3 | Page : 153-154 |
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Reducing cataract surgery-related complications
J Ram
Correspondence Address:
J Ram
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 10858769 
How to cite this article:
Ram J. Reducing cataract surgery-related complications. Indian J Ophthalmol 1999;47:153-4 |
Cataract is the number one target for reducing blindness in India.[1] A recent survey conducted by us in rural Punjab showed that 17% of the cataract-operated eyes were blind (unpublished data).The surgical techniques used for cataract surgery by the majority of ophthalmic surgeons in our country are large-incision intracapsular and extracapsular surgery.[2],[3] Phacoemulsification is the procedure of choice for cataract surgery in the industrialized world and it is rapidly gaining popularity in India. This issue of the Journal reports three studies on cataract surgery-related complications.
Compared to retrobulbar anaesthesia, peribulbar anaesthesia is a safe and effective technique which results in fewer complications.[4] However, perforation of the globe may occur even with peribulbar anaesthsia. In this issue, Puri et al report perforation of globe in 8 patients resulting from peribulbar anaesthesia. The authors noted this complication before or during surgery in 3 cases by observing intraoperative hyphema, very soft eye, or loss of red reflex. In 4 cases diagnosis was established within a week and in one case at 3 weeks after surgery. In this series, 6 of 8 eyes achieved 6/12 or better visual acuity after appropriate management. The most crucial factor in such situations is to identify high-risk cases and to have a high index of suspicion when globe perforation occurs. We need to identify eyes with high risk for globe perforation during anaesthesia such as high myopia, posterior staphyloma, prominent eyes, scleral buckled eyes, and shallow orbit.
Ophthalmologists should remember that following correct procedure and adopting the right technique while giving peribulbar or retrobulbar injection will prevent this catastrophic complication. The needle should be inserted parallel to the floor of the orbit rather than directed towards the globe. The use of a blunt and short needle may help prevent this complication. Sudden firming of globe or hypotony noticed during injection of the anaesthesia should immediately alert the ophthalmologist of globe perforation. Experienced ophthalmologists must supervise the administration of local anaesthesia by trainees.
One of the major blocks to the widespread adoption of phacoemulsification in our country is the fear of intraoperative complications. Among the preventable complications of phacoemulsification are: 1) operative: incision-related, radial and posterior capsule tear, dislocation of nucleus; 2) early postoperative: endoophthalmitis; 3) late postoperative: posterior capsule opacification,[5] and decentration of lenses.[6] Most of the complications in transition can be reduced by learning phacoemulsification through skill transfer courses in the wet lab.[7] In an excellent study in this issue, Mathai and Thomas report an 0.8% incidence of nucleus drop during phacoemulsification. Authors reported favorable visual outcome following management of dislocated nucleus by using pars plana vitrectomy. The authors have rightly concluded that referral facilities should be available to the operating surgeon in case of such eventuality.
When a significant fragment of the nucleus dislocates into vitreous during phacoemulsification, the surgeon should not go "fishing" or "hunting" for the lost nucleus in the vitreous cavity. Infusion should be lowered to avoid mixing vitreous with cortical matter. Anterior vitrectomy should be performed using the bi-manual technique. Posterior capsule support should be assessed for implantation of posterior chamber IOL in the sulcus or capsular bag. It is better to leave the management of a dislocated nucleus to a vitreo-retinal surgeon. Patients with this complication are at a high risk for developing omplications such as glaucoma, uveitis, cystoid macular edema and retinal detachment.[8] Identification of high-risk cases for development of posterior capsule tear during phacoemulsification, such as posterior polar cataracts, is a must.
In this issue, Srinivasan et al report positive culture for bacteria in 37% of eyes from anterior chamber aspirate during extracapsular cataract surgery. Dickey et al reported contamination of aqueous with bacterial organisms in 43% of eyes having uneventful cataract surgery.[9] Use of a preoperative topical antibiotic, application of plastic drape to isolate the eyelid margins and eyelashes from the operative field and instillation of povidone-idione into conjunctival sac has drastically reduced the postoperative infection in cataract surgery. The surgeons need to be reminded that meticulous surgical techniques including ensuring the sterility of instruments, intraocular fluids, viscoelastic agents and intraocular lenses must be strictly adhered to.
| References | |  |
| 1. | Dandona L, Dandona R, Naduvilath T, McCarty CA, Nanda A, Srinivas M, et al. Is current eye-care-policy focus almost exclusively on cataract adequate to deal with blindness in India? Lancet 1998;351:1312-16.  |
| 2. | Ram J. Cataract blindness in India. Lancet 1994;343:1228. [ PUBMED] |
| 3. | Apple DJ, Ram J, Auffarth GU, Brown SJ. Saudi ophthalmological gold medal lecture:cataract surgery in the developing world. Saudi J Ophthalmol 1995;9:2-15. |
| 4. | Duker JS, Belmont JB, Benson WE, Brooks HL Jr, Brown GC, Federman JL, et al. Inadvertent globe perforation during retrobulbar and peribulbar anaesthsia. Patient characteristics, surgical management, and visual outcome. Ophthalmology 1991;98:519-26. [ PUBMED] |
| 5. | Ram J, Apple DJ, Peng Q, Visessook N, Auffarth GU, Schoderbek RJ Jr, et al. Update on fixation of rigid and foldable posterior chamber intraocular lenses. Part II: Choosing the correct haptic fixation and intraocular lens design to help eradicate posterior capsule opacification. Ophthalmology 1999;106:891-900. [ PUBMED] |
| 6. | Ram J, Apple DJ, Peng Q, Visessook N, Auffarth GU, Schoderbek RJ Jr, et al. Update on fixation of rigid and foldable posterior chamber intraocular lenses. Part I: Elimination of fixation-induced decentration to achieve precise optical correction and visual rehabilitation. Ophthalmology 1999;106:883-90. [ PUBMED] |
| 7. | Ram J,. Wesendahi TA, Auffarth GU, Apple DJ. Miyake posterior video view technique helps to reduce learning curve in phacoemulsification. Ophthalmic Practice 1994;1:11-16. |
| 8. | Fasternburg Dm, Schwartzz PL, Shakin JL, Golub BM. Management of dislocated nuclear fragments after phacoemulsification. Am J Ophthalmol 1991;112:535-39. |
| 9. | Dickey JB, Thompson KD, Jay WM. Anterior chamber aspirate cultures after uncomplicated cataract surgery. Am J Ophthalmol 1991;112:278-82. [ PUBMED] |
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