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
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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
| 1 | Galin, M.A. Bonium V, Obstbaum, S, and Glasser, M. 1975 Trans OphthalmolSoc UK 95:42-45. |
| 2 | Mehta, H.K. 1977: Trans Ophthalmol Soc UK 97: 117-23. |
| 3 | Mehta, H.K. 1976; Trans OphthalmolSoc UK 96:18488. |
| 4 | Bruns. H.D. Trans Am OphthalmolSoc 1915-16; 14:473-82. |
| 5 | Jervey, J.W. 1971; Trans Am Ophthalmol Soc 69:263-67. |
| 6 | Williamson, D.E. 1975; The Eye, Ear, Nose & Throat Monthly: 54:52-60. |
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