Indian Journal of Ophthalmology

ARTICLES
Year
: 1983  |  Volume : 31  |  Issue : 7  |  Page : 847--852

Day surgery for cataracts and iris-clip implant insertions


Hemant K Mehta, Mrinalini H Mehta 
 Eye and Cottale Hospital, Caernarvon, Gwynedo, North Wales, United Kingdom

Correspondence Address:
Hemant K Mehta
Derwen DEG, Bangor, Gwynedd, Wales
United Kingdom




How to cite this article:
Mehta HK, Mehta MH. Day surgery for cataracts and iris-clip implant insertions.Indian J Ophthalmol 1983;31:847-852


How to cite this URL:
Mehta HK, Mehta MH. Day surgery for cataracts and iris-clip implant insertions. Indian J Ophthalmol [serial online] 1983 [cited 2021 Sep 21 ];31:847-852
Available from: https://www.ijo.in/text.asp?1983/31/7/847/29684


Full Text

The first randomised trial on day care cataract surgery was reported by Galin and as­sociates[1]. In the U.K. Mehta[2] first reported day surgery in a selected group of 32 patients who underwent simple cataract extractions as well as cataract extractions combined with trabeculectomy or iris-clip implant insertion. This randomised study of 391 cataract extrac­tions including 116 first stage iris-clip implant insertions is a sequel to that pilot study.

 MATERIAL & METHODS



It was intended to include 400 patients in a randomised trial which was to last 3 years in­clusive of minimum follow-up of 6 months. A protocol was established in April 1977. Of the 400 patients given the random allocation, it was possible to operate upon 391 patients [Table 1]. Of those 198 patients (Group A) underwent the surgery as day case, and 193 pa­tients (Group B) were admitted to the hospi­tal, and were discharged 48 hours post-operat­rively.

The youngest patient was 22 years old, and the oldest was 9~. The average being 72.9 years.

Surgical management

Simple intracapsular cataract extractions among 245 eyes (62.7%) of the randomised study were carried out by limbal section and 6 preplaced cornea-scleral sutures of filament silk. Corneal sections were implemented in 146 eyes (37.3%) in patients who were scheduled to have cataract extraction with in­sertion of an iris-clip implant, or in patients who hjad mechanical factors (like a filtration bleb from previous glaucoma surgery promi­nent limbal vessels, or bleeding tendency) that contra-indicated a limbal section. Almost all­patients undergoing surgery as day cases at­tended the hospital at about 8.00 a.m. and were examined by the surgeon (HKM) by 8.15 a.m. No premeditation was given to those having surgery under local anaesthesia. Patients scheduled for surgery under local anaes­thesia walked to the operating theatre. No lid suture or speculum was used.The eye was kept open with a 4/0 silk stay suture each for the superior and inferior rectos muscles. All surgery was carried out under the Zeiss OP­MI 6 microscope.

Postoperative Management:

On completion of the operation, all patients were given subconjunctival injection of Gen­tamicin 20 mgm, methylprednisolone acetate (Depomedrone) 20 mgm, and hydrocortisone sodium phosphate (Efcortesol) 100 mg. In ad­dition, patients who had iris-clip implant inser­tion received 0.1 ml of 4% Pilocarpine subcon­junctivally as reported previously, Mehra[3]. Chloramphenicol and hydrocortisone - Neomycin ointments were instilled and a car­tella shield was applied as the sole dressing. Daycases were allowed home between I and 5 hours post-operatively. All patients were given 2 co-trimoxazole (Septram) tablets twice daily for 5 days, and Chloramphenicol and hydrocortisone - Neomycin ointments twice daily for 3 weeks. Pilocarpine 2% dropos twice daily were prescribed for patients who had iris­clip implant insertions. The first dressing and subsequent visits of the patients were as fol­lows:

Day Patients: 1st Visit at 48 hours (implants at 24 hours) for first dressing; 5th postoperative day, and then at the following post-operative weeks: 2 weeks; 3 weeks (corneal suture usu­ally removed at this visit); 5 weeks; 9 weeks; 17 weeks; 27 weeks; 30 weeks and at 6 monthly intervals after that. The admitted patients and the day group had identical first dressing and clinic follow-up regimen.

In December 1980, (i.e. 5 months after the completion of the trial) a questionnaire was posted to all surviving patients, to assess as to whether trhey preferred day surgery; an in-pa­tient stay, or whether theyhad no strong pre­ference either way. Their response is analysed in [Table 2].

 OBSERVATIONS



Three hundred and ninety one patients par­ticipated in the trial. Of these 198 were day cases, and 193 were in-patients. There was no significant differences between these 2 groups in terms of age, sex, marital status and dura­tion and type of survery: (i) Failures

If a patient with a random allocation for day surgery requested or needed tobe kept admit­ted overnight in the hospoital, this was inter­pretted as a failed day case.

Similary if a person with an in-patient allo­cation, either wished to go home on the day of surgery, or willingly overstayed or needed to 'be kept admitted to the hospital for longer than 2 postoperative nights, it has interpreted as a failed in-patient. There were l 1 failures among day cases, and 9 failures among in-pa­tients. [Table 3].

(ii) Complications

There were 29 surgical and post-operative complications in 26 eyes - 11 day cases, and 15 in-patients. [Table 4].

During the same period there were 9 "failed" in-patients, with 7 patients wanting to go and allowed home on the day of surgery (all uner local anaesthesia, and 1 patient had implant insertion). One patient with implant insertion want home at 24 hours after first dressing, and 1 patient insisting on staying for 4 days.

(iii) Visual Results

These were analysed in details by a computer program which considered several factors, surgical and parasurgical and emerged with the conclusion that there was little difference in the visual results at 3 and 12 months, bet­ween the day cases and in-patients - [Table 5]. There were 34 cases (8.7%) of cystoid maculopathy among the 391 RCT patients, with ultimate visual improvement to 6/9 or better in 21 patients (12 implants - 7 day cases and 5 in-patients; and 9 simple cataract extrac­tions of which 5 were day cases, and 4 were in­patients); and permanent worsening of vision below 6/18 in 13 patients (3.3%) of which 8 were implants in 5 day cases and 3 in-patients, and 5 were simple cataract extractions among 1 day case and 4 in-patients.

 DISCUSSION



The 3 significant conclusions of the compu­ter analysis oif this study are, firstly that the visual results were almost identical in the day­cases and in-patients; secondly, that there was no different in the nature, frequency and sev­erity of complications in the 2 groups, and lastly that there was no complication that .could be attributed to day surgery or to im­mediate and unrestricxted postoperative ac­tivity.

There were 100 cases who were excluded from the trial [Table 6]. Our criteria for exclu­sion, though proper from ethical and legal view points,were in fact two stringent from the practical aspect. At least 60 of these excluded 100 patients could have been treated as day cases.

It is not generally known that in the U.S.A., betwen 1908 and 1915, Bruns performed 232 "entirely unselected" day case cataract extrac­tions. His incidence of complications in trhese day cases was 3% lower than that in his 371 cataract extractions managed as in-patients. The incidence of complications of just over 7% in his day cases is even more impressive, when we learn that his limbal sections with an undi­vided junjunctival bridge were Heft unsutured, and that immediately after the operations the patients walked home (one patient walked 5 miles) or to a street-car to return home.

Jervey [5] reported on his own over 450 day case cataracts. He concluded that hospitalisa­tion of patients neither prevented complica­tions nor insured better care provided day case cataract surgery was based on "on a very sec­ure wound". He used corneal sections and 3 to 5 sutures of 7-0 Silk.

Williamson[6] reported on 1000 consecutive daycase cataract extractions he performed be­tween 1969 and 1973, under local anaesthesia, with Graefe knife sectionunder an operating microscope.

Our randomised trial reported here differs from the randomised trials of Galin and as­sociates[1] in containing a much larger number of 391 patients, and by the fact that ours is the first randomised trial to include intra-ocular implant insertions, and that nearly 1/6 of our patients had surgery under general anaes­thesia. Our clinical outcome of day case cataract extractions as well as primary implant surgery in no way differs from that of surgery performed on in-patients basis. We would therefore, continue to practice day case cataract surgery, and recommend its practice to other Ophthalmic Surgeons with similar ap­titude and temperament.

 SUMMARY



This study reports the results of a ran­domised trial of 391 cataract extractions in­cluding 116 first tage iris-clip implant inser­tions. The patients were randomly allocated to 2 groups. Group A - 198 patients - was treated on a day care basis, returning home within 6 hours after the operation; and Group B - 193 patients - was admitted for surgeryand allowed home 48 hours post-operatively. Patients hav­ing simple cataract extrations had limbal sec­tion and 6 corneo-scleral sutures. Patients in­tended for cataract extractions and simultane­ous iris-clip implant insertions underwent a corneal section.There was no difference in the final visual result or post-operative complica­tions between the day cases and in-patients, nor was there any complication that could be attributed to day surgery.

Acknowledgement: This study was fully supported by a grant from the Welsh. Scheme for the development of health and social re­search. I would like to express my gratitude to Mr. Peter Graham, F.R.C.S, Cardiff, for his help and guidance in establishing the protocol, and analysing the results: and to Professor Hubert Campbell, Department of Medical Statistics, University Hospital of Wales, Car­diff, for providing the random allocation num­bers.

References

1Galin, M.A. Bonium V, Obstbaum, S, and Glasser, M. 1975 Trans OphthalmolSoc UK 95:42-45.
2Mehta, H.K. 1977: Trans Ophthalmol Soc UK 97: 117-23.
3Mehta, H.K. 1976; Trans OphthalmolSoc UK 96:184­88.
4Bruns. H.D. Trans Am OphthalmolSoc 1915-16; 14:473-82.
5Jervey, J.W. 1971; Trans Am Ophthalmol Soc 69:263-67.
6Williamson, D.E. 1975; The Eye, Ear, Nose & Throat Monthly: 54:52-60.