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| EDITORIAL |
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| Year : 1999 | Volume
: 47
| Issue : 4 | Page : 213-214 |
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Current and future trends in cataract surgery
A Vasavada
Correspondence Address:
A Vasavada
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 10892475 
How to cite this article:
Vasavada A. Current and future trends in cataract surgery. Indian J Ophthalmol 1999;47:213-4 |
The ultimate goal of a cataract surgery is to restore and maintain the precataract vision and to alleviate the other cataract-related symptoms. In the quest for perfection, the techniques and approaches followed by cataract surgeons have constantly evolved over the years. Despite the rapid strides in technology-driven cataract surgery in the developed world, it is still in its infancy in the developing countries. Hence a realistic portrayal of the trends in cataract surgery can best be described as a wide spectrum ranging from Intra Capsular Cataract Extraction (ICCE) to LASER-assisted cataract removal. Such a diversity of trends is governed by multiple factors, most pertinent of which are economy, patients' awareness, surgeons' calibre and the cataract backlog.
In a recent survey (1998) on the practice styles of American Society of Cataract and Refractive Surgeons (ASCRS) members, it was found that only 3% of the cataract surgeons did not use the phacoemulsification (phaco) technique at all. About 65% of cataract surgeons perform phaco alone (from 58% in 1996 and 63% in 1997).[1] Basti has reported that less than 5% of the surgeons in India perform phaco.[2] On the other hand, over the past two decades, extra-capsular cataract extraction (ECCE) has overtaken ICCE, which is now performed only by a few surgeons in rural India and in the eye camps held to combat the massive cataract backlog.
In 1997, it was estimated that 5.4 million persons, according to visual acuity <3/60 and 11.5 million according to visual acuity <6/60, were bilaterally blind in India.[3] This modern-day tragedy has dictated that at least in rural India, the quantity of cataract surgery takes precedence over its quality. Hence this wide chasm in the trends between the rural and urban areas of India; this is probably also reflected in other developing countries. In a survey conducted in 1992, of the 2000 ophthalmologists who responded, 82.8% reported some experience with ECCE and 73.1% with ECCE and IOL.[4] This probably still reflects the trend of cataract surgery among the estimated 10,000 ophthalmologists in this country today, albeit with a wider use of IOL implantation than before. Hence, it would be fair to say that the current surgical trend for the majority of the surgeons in the developing world is towards ECCE and IOL implantation. Non-phaco, small-incision ECCE techniques are becoming quite popular for those who have accepted the challenges of transition towards a better technique but have limited resources. Perhaps about 5-10% of the cataract surgeons in India routinely perform phaco. However, published reports in peer-reviewed literature from some of them, regarding their experiences of phaco in difficult cataracts,[5],[6] indicate that their precision and quality is accepted. This is reflected in the current trend of preoperative slitlamp biomicroscopy, routinely performed biometry and keratometry evaluation, wider use of good quality microscopes and affordable viscoelastics such as methyl cellulose.
The phaco technique, which allows an exquisite intraoperative control and a consistent closed-chamber removal of cataract, undoubtedly reigns supreme in the developed countries. This technique has brought cataract surgery results as close to anatomical perfection as possible with the current technology and skills. In order to increase safety and to achieve faster visual rehabilitation for their patients, many surgeons are now adopting topical anaesthesia with an adjunctive intracameral 1% lidocaine1 instead of the peribulbar variety which is still popular with most surgeons around the world. Incisions are progressing towards temporal clear cornea which affords easier access to the cataract under topical anaesthesia. Understanding the distinctive uses of the newer dispersive and cohesive viscoelastics has helped ensure better corneal endothelial protection during phaco. Of the wide range of phaco techniques developed to suit different cataracts and their related conditions, surgeons today strive for those that ensure an endocapsular phaco. This is obviously due to the far superior long-term outcome observed following phaco at the plane of 'capsular cave'.
Phacoemulsification is a prime example of technology assisting a surgeon's skills. The newer advances in phacomachines and tip ergonomics have ensured that those who are aware and those who can afford it, reap the benefits of these leaps in science and technology. In the constant struggle to keep the incision size to a minimum, foldable lenses are welcomed everywhere. Some of them are developed with a complementary injector system which allows a surgeon the luxury of enlarging his phaco incision only marginally.
Among those available presently, the IOL that promises the optimum host response owing to its design and material is rapidly gaming popularity i.e., Acrysof. Hence, considering the laudable outcome of phacoemulsification, it appears that it is certainly not in a hurry to be displaced from its position of favour in the developed countries. In fact the consistent predictability of its outcome has led to a new avenue -refractive cataract surgery, resulting in phakic IOL, piggy back IOL and clear lens extraction. However cataract surgeons, in their relentless pursuit of perfection and excellence, are still looking into the probable advantages of other available options like ultrasound assisted by a secondary energy source such as PhacoTmesis, and fluid-assisted cataract removal, Catarex™and pulsed hot water technology (being patented by Dr. Mark Andrew and developed by Alcon Surgical) and the much debated LASER-assisted cataract removal. Although some of these alternative futuristic techniques are available toda, they have not been extensively adopted.
In this issue Dr. Aasuri and Dr. Basti have, very meticulously and comprehensively, discussed the mechanics as well as the pros and cons of these techniques.[7] I concur with the authors' judgement that it would be prudent to await further refinement and trial of these alternative techniques before pursuing any of them in lieu of phaco.
Posterior capsule opacification (PCO) is the prime deleterious consequence of cataract surgery. This aphoristic concern over the clarity of the posterior capsule shall undoubtedly dominate the future arenas of research and innovation. Presently, improving the IOL design and material appears to be a more practical means of reducing the incidence of PCO. The use of accommodative IOL material too has a bright future if absence of capsular opacification can be ensured. The current experimentation and innovation to perfect the chemoemulsification technique may turn out to be an easier alternative. The concept of implanting an intraocular drug delivery device at the end of cataract surgery is in its infancy. Its routine use in future may definitely bring significant relief to a surgeon from the worries of patient compliance and ensure an excellent round-the-clock postoperative medical control. On this hopeful note for the future, I would like to reiterate that for a developing country like India, the phacoemulsification technique is definitely on the rise for most of us in the next decade.
| References | |  |
| 1. | Learning DV. Practice styles and preferences of ASCRS members - 1998 survey. J Cataract Refract Surg 1999;25:851-59.  |
| 2. | Basti S. Cataract surgery in emerging nations:role of phacoemulsification. In Masket S., Crandall AS., editors. Atlas of Cataract Surgery. London:Martin Dunitz Ltd; 1999. p 105-10. |
| 3. | Limburg H, Foster A, Vaidyanathan K, Dada T, Data VK. Monitoring visual outcome of cataract surgery in India. WHO Bull 1999;77:455-60. |
| 4. | Gupta AK, Ellwein LB. The pattern of cataract surgery in India: 1992. Indian J Ophthalmolol 1995;43:3-8. |
| 5. | Vasavada A, Singh R. Phacoemulsification in eyes with posterior polar cataract. J Cataract Refract Surg 1999;25:238-45. [ PUBMED] |
| 6. | Vajpayee RB, Bansal A, Sharma N, Murthy GV. Phacoemulsification of white hypermature cataract. J Cataract Refract Surg 1999;25:1157-60. |
| 7. | Aasmi MK, Basti S. Laser-assisted cataract surgery and other emerging technologies for cataract removal. Indian J Ophthalmol 1999;47:215-22. |
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