Techniques on handling hard and soft cataracts

To assess the safety and efficacy of Manual Small Incision Cataract Surgery (MSICS) in cases of white cataract with the use of trypan blue as an adjunct for performing continuous curvilinear capsulorthexis (CCC). Prospective observational study on 100 consecutive eyes of 100 patients with white cataract who had undergone MSICS with trypan blue assisted CCC. The nucleus was prolapsed into anterior chamber by using a sinskey hook and extracted out of the eye using irrigating vectis. Intraoperative and postoperative findings (according to OCTET classification) as well as postoperative visual outcomes were used as main measures to report the safety and efficacy of the surgery. Of the 100 eyes, 16 had intumescent, 67 had mature and 17 had hypermature cataract. Intraoperatively CCC was incomplete in 4 eyes (4%) and had to be converted to canopener capsulotomy. None of the eyes had posterior capsular rupture or zonular dialysis and no eyes were converted to conventional Extra Capsular Cataract Extraction (ECCE). Postoperatively, 6 eyes (6%) developed corneal oedema with >10 Descemets folds and 7 eyes (7%) had corneal oedema with In developing countries like India where phacoemulsification may not be affordable to a majority of those requiring cataract surgery, MSICS proves to be a safe and efficacious alternative for white cataracts especially with the adjunctive use of trypan blue dye.

Abstract
 Purpose 
 To evaluate the intraoperative difficulty, complications and post operative outcome in patients with white mature cataracts undergoing phacomulsification and foldable intraocular lens implantation and to develop a strategy for achieving continuous curvilinear capsulorhexis in these cases.
 Study design
 Descriptive case series
 Place and duration 
 Ophthalmology department of Holy family hospital, Rawalpindi in six months interval since January 2017 to June 2017
 Material and Methods 
 50 Patients who had senile white mature cataract were enrolled in this prospective study .Detailed preoperative and intraoperative notes were made. A small capsulorhexis was attempted initially after staining capsule with trypan blue .An initial cut was made with cystotome and it was enlarged with utrata forceps. Endophacomulsification was done with stop and chop technique. Intraoperative difficulties related to continuous curvilinear capsulorhexis, phacomulsification and post operative visual outcomes were analyzed.post operative examinations were done at day 1,1st week,1st month and 3rd month.
 Results
 There were 28 males (56%) and 22 females (44%).The mean age was 63.18±7.997 standard deviation years(48-78).The mean preoperative best corrected visual acuity BCVA was 0.0276±0.013 (SD)Snellen, decimal(0.01-0.05) and the mean post operative BCVA was 0.638±0.305 (SD) Snellen, decimal(0.1-1.0) .Mean phaco time was 4.08±1.03 (SD)mins(2.08-6.66).The mean preoperative intraocular pressure IOP was 15.90±1.799 (SD)mmHg (12-22) and mean post op IOP was 11.98±2.035 (SD) mmHg(10-18) .Posterior capsular rupture occurred in 3 (6%) , vitreous loss occurred in 1 (2%) patients. 5 (10%) cases were converted to extra capsular cataract extraction (ECCE). Postoperatively 10 (20%) patients had transient corneal edema, 3 patients (6%) had persistent corneal edema and corneal burn treated with steroids and hyper osmotic agents.
 Conclusion 
 The intraoperative and postoperative complications rate is higher in white mature cataracts. White mature cataract is a challenge for cataract surgeon, yet by means of additional dyes and proper techniques and expertise, the rate of complications can be reduced.
 Keywords
 Phacomulsification, continuous curvilinear capsulorhexis, senile mature cataract, trypan blue, posterior capsular rupture, persistent corneal edema

Purpose: The purpose of this study is to determine the percentage of difficult cataracts out of total cataracts admitted in a tertiary care center, to study the intra- and postoperative complications in patients with difficult cataracts undergoing cataract surgery, and to determine their visual outcomes. Materials and Methods: This is a retrospective, noncomparative, single-institutional, observational study. The study was conducted on patients who were admitted over 2 years (January 2013–December 2014). Of these, patients with difficult cataracts (according to inclusion criteria) were screened and preoperatively evaluated. These patients underwent manual small incision cataract surgery and were followed up on the 1st, 7th, and 40th postoperative days. These cases were monitored for postoperative visual acuity (VA) and complications. The postoperative complications were graded according to the Oxford Cataract Treatment and Evaluation Team (OCTET) definitions and analyzed. Results: Of 5766 patients, 1858 (32.2%) patients presented with difficult cataracts. Hypermature and mature cataracts (24.9%), hard cataracts (20.02%), and pseudoexfoliation (33.04%) constituted as the major causes. Of these, 820 (44.1%) patients presented with no complications postoperatively. According to the OCTET grading, 44.9% of patients had Grade I, 9.5% had Grade II, and 1.83% had Grade III complications; the most common postoperative complication was corneal edema (39.2%). A total of 21.9% had VA 6/18 increased from 44.1% on day 1 to 61.8% on day 40 (P

Phacoemulsification versus manual small-incision cataract surgery for white cataract

Early Experience with the Femtosecond Laser for Cataract Surgery

To describe the cataract surgery outcomes in 34 adult patients with Down's syndrome in our center between 1996 and 2019. Clinical practice, tertiary hospital in Madrid, Spain. Retrospective, descriptive study in which 34 patients with Down's syndrome who underwent cataract surgery in our center between 1996 and 2019 were included. Socio-demographic and clinical data such as the type of cataract, the keratometry and biometry, the type of surgery, the IOL material, and the complications before and after surgery were recovered. Fifty-four eyes of 34 patients (23 female, 11 male, mean age 49 ± 8years) underwent cataract surgery with general anesthesia. Immediately sequential, bilateral cataract surgery was performed in 18 patients (90% of bilateral cases). White cataract was found in 11 eyes (20.4%). Phacoemulsification technique was used in 51 eyes, extracapsular technique in 2 eyes (3.7%), and intracapsular technique in 1 eye (1.85%) (the only aphakic eye after surgery). The mean Km was 48.73 ± 4D, and the mean axial length was 25.2 ± 2.5mm. The most frequent ocular comorbidity was myopia (27 eyes, 50%) followed by strabismus (11 eyes, 20.4%) and keratoconus (10 eyes, 18.5%). Posterior capsular rupture as a complication during surgery was found in 3 eyes (5.5%). The mean preoperative visual acuity was 0.8 ± 0.2 logMAR, and the mean postoperative visual acuity was 0.5 ± 0.18 logMAR. Phacoemulsification technique can be performed in adults with Down's syndrome with an acceptable rate of complications. The lack of patient cooperation, the ocular comorbidities and the challenging biometric estimation must be considered in surgical planning. It seems reasonable to perform immediately sequential, bilateral cataract surgery when possible, in order to reduce the exposure to general anesthesia.

We described a novel "flow capsulorhexis" technique in white and hypermature cataracts and compared it with the standard "needle decompression capsulorhexis" technique. Six hundred and eight eyes of 420 patients with intumescent or non-intumescent mature white cataracts who had undergone phacoemulsification or manual small incision cataract surgery with "flow capsulorhexis" (Group 1) or "needle decompression capsulorhexis" (Group 2) were assessed. The mean continuous curvilinear capsulorhexis (CCC) completion time was 6.6 ± 3.4 seconds in Group 1 and 10.4 ± 4.2 seconds in Group 2 (P < 0.001). The mean number of times for an ophthalmic viscosurgical device (OVD) supplement was 0.4 ± 0.2 and 1.8 ± 0.8 in Group 1 and Group 2, respectively (P < 0.001). CCC success rate was 95.8% in Group 1 and 87.2% in Group 2 (P = 0.001). The new technique was observed to have better outcomes in terms of surgical time, OVD supplement times, and success rate than the standard needle decompression technique.

Effect of cataract surgery on the corneal endothelium: Modern phacoemulsification compared with extracapsular cataract surgery

Background: To evaluate the safety and efficacy of micro-incisional cataract surgery (MICS) with bimanual phacoemulsification for the management of white mature cataract. Methods: Twenty-five eyes in 25 patients with mature cataract were prospectively recruited to undergo MICS with bimanual phacoemulsification. Serial changes in best-corrected visual acuity (BCVA), central corneal thickness (CCT) and endothelial cell density (ECD) were compared using the Wilcoxon signed-rank test. Results: MICS was successfully performed in 24 (96%) of the 25 eyes, with 1 eye requiring conversion to extracapsular cataract extraction due to radial tear during continuous curvilinear capsulorhexis. The median preoperative BCVA was hand movement. On day 1 postoperatively, the median BCVA improved to 0.6 (p < 0.001 compared with baseline). All patients had BCVA of 0.6 or better at 3 months after surgery (p < 0.001 compared with baseline). The mean increase in CCT at day 1 and week 1 postoperatively was 11.5 and 7.1%, respectively. The change in mean CCT was no longer significant at month 3 postoperatively (p = 0.82). The mean reduction in ECD at 3 months postoperatively was 7.8% (p = 0.037). None of the patients developed any postoperative complications. Conclusions: MICS with bimanual phacoemulsification appeared to be a promising alterative for the management of white mature cataract.

To review the indications, dosages, and safety profiles of intracameral drugs used during cataract surgery. A narrative review was conducted, evaluating published clinical studies, review articles, and guidelines related to intracameral drug use in cataract surgery. The analysis focused on drugs commonly used for anesthesia, mydriasis, inflammation control, and intraoperative complication management. Special consideration was given to their utility in high-risk surgical scenarios, such as small pupils, intraoperative floppy iris syndrome, white or pediatric cataracts, and cases with zonular weakness. Intracameral drugs have proven beneficial in achieving effective anesthesia, maintaining pupil dilation, and controlling inflammation during cataract surgery. Their use is particularly advantageous in complex cases, including those with corneal opacity, posterior capsular rupture, or combined procedures like minimally invasive glaucoma surgery and premium IOL implantation. When prepared and administered properly, these agents contribute to safer and more efficient surgeries. However, improper preparation or dosing can lead to ocular toxicity, highlighting the importance of meticulous handling. Intracameral drug administration is a valuable adjunct in cataract surgery, enabling surgeons to manage routine and complex cases more effectively. Understanding their appropriate use and potential risks is essential to maximize patient safety and surgical success.

Objective To compare the clinical efficacy of manual small-incision cataract surgery with phacoemusification in the management of hard nuclear cataract.Methods 404 eyes of 386 senile cataract with hard nuclei grade over Ⅲ were randomly divided into two groups:small-incision cataract surgery group (206 eyes of 194 cases) and phacoemusification group (198 eyes of 192 cases).Primary intraocular lenses implantation were performed in all cases.The postoperaive visual acuities,corneal astigmatism and surgical complications were compared between two groups.Results For cataract patients with grade Ⅲ hard nuclei,there were no significant differences in postoperative visual acuities,corneal astigmatism,posterior capsule rupture and corneal edema beween two groups.For cataract paients with grade Ⅳ or Ⅴ hard nuclei,the incidence of corneal edema was much lower in manual small-incision cataract surgery group than phacoemusification group,and the difference was statistically significant.Conclusion Small-incision cataract surgery is safe,time-saving and easy to operate which is the ideal choice for hard nuclear cataract patients in rural hospital. Key words: Cataract, nuleus, hard; Surgery, cataract, small-incision; Phacoemusification

Objective To observe ip functions of OZil torsional Intelligent mode in the application of hard nuclear cataract phacoemulsification.Methods One hundred and sixty patients (200 eyes) with degree Ⅳ nuclear cataract were randomly divided into group A and B.The cataract surgery was done with OZil torsional intelligent phacoemulsification mode in group A,with traditional phacoemulsification mode in group B.The situations of the anterior chamber stability,energy release time and the rate of obstruction in the needle were observed.Results Anterior chamber stability in group A was better than that in group B (P ＜0.05).The intraoperative ultrasound time in group A was obviously less than that in group B (P ＜0.01).The rate of the needle obstruction in group A was less than that in group B (P ＜0.05).The visual acuity of group A was better than that of group B at the first day after surgery (P ＜0.01).Conclusions The application of ip functions of OZil torsional phacoemulsification in hard nuclear cataract surgery is efficient,safe and intellective. Key words: OZil torsional intelligent phacoemulsification; ip; Hard nuclear cataract surgery

Objective To compare the efficacy of small incision extracapsular cataract extraction (ECCE) and phacoemulsification for cataract patients and the impact on tear film break-up time (BUT) and tear secretion test (SIT) levels. Methods 84 cases of cataract patients in our hospital from December 2015 to December 2016 were selected, and were divided into observation group and control group according to the time of treatment, 42 cases in each group. The patients in the control group were treated with phacoemulsification, while the patients in the observation group were treated with small incision extracapsular cataract extraction. All patients were followed up for 12 weeks. The postoperative visual acuity, average astigmatism, changes of BUT and SIT levels and complications were compared between the two groups. Results After 1 week, 4 weeks, and 12 weeks, the visual acuity recovery rates of the two groups were not significantly different, without statistically significant differences (P>0.05). After 1 week, 4 weeks, 12 weeks, the average astigmatism of the two groups were not significantly different, without statistically significant differences (P>0.05). After treatment, the BUT and SIT levels of the two groups were significantly higher than those before treatment, while the differences between the two groups were not significant (P>0.05). After treatment, there were no statistically significant differences in the incidences of iris injury, corneal edema, posterior capsular rupture, and transient high intraocular pressure between the two groups (P>0.05). Conclusion Small incision extracapsular cataract extraction and phacoemulsification in the treatment of cataract have similar clinical efficacy, which can effectively improve the tear secretion function of patients, and effectively control the tear film break-up time, with good safety. Key words: Cataract; Extracapsular cataract extraction with small incision; Phacoemulsification; Tear film break-up time; Tear secretion function

To examine the incidence, characteristics and outcomes of posterior capsular rupture (PCR) cases amongst the ophthalmology trainees and to evaluate the trainees' confidence in managing PCR. A two-staged cross-sectional study was carried out between September 2017 and April 2018 in the North East of England, UK. All ophthalmology trainees were surveyed on their confidence level in managing PCR and the characteristics and outcomes of their PCR cases. Fifteen (71.4%) out of 21 trainees completed the study. The mean number of phacoemulsification was 268.9 ± 250.9 cases (range, 0-705) per trainee. There were 82 (1.9%) cases of PCR reported among 4303 phacoemulsification. PCR occurred most commonly during quadrant removal (44.0%) and cortex removal (21.3%). The best-corrected visual acuity (in logMAR) improved significantly from 0.47 ± 0.32 preoperatively to 0.20 ± 0.19 postoperatively (p < 0.001). The supervising consultant took over 80.5% of the PCR cases. The PCR rate decreased significantly from 3.1% at 0-100 cases to 0.6% at 301-400 cases (p = 0.004) and to 0.4% at >500 cases (p = 0.005). Confidence in managing PCR (without supervision) improved from 0% (9/9) at junior level to 50% (3/6) at senior level, and the average number of anterior vitrectomies performed was 0.6 ± 0.9 (range: 0.0-2.0). We observed a low PCR rate among the trainees in our region, with the majority of cases achieving good visual outcome. A significant reduction in PCR rate was observed at the threshold of >500 cases. There is however a lack of confidence among trainees in managing PCR, highlighting the need for devising new training strategies in this area.

Purpose There are no objective parameter allowing to predict the risk of surgical difficulties in white hyper mature cataracts. Lens density can be assessed by pentacam, but this tool is not commonly available. Our purpose was to assess the correlation between lens thickness (LT) and surgery complications.Methods We conducted a prospective, observational, and monocentric study. We included all patients operated on for white hyper mature cataract from january 2013 to march 2014. We selected patients with a visual acuity (VA) lower than 20/200 on the Monoyer scale. We excluded patients suspect of zonula fibers weakness. Morphological features assessed were LT, axial length, depth of anterior chamber and vitreous length, measured by A or B ulrasound scan. The other parameters assessed were the surgical duration, complications during surgery, VA and corneal edema at the seventh day after surgery (analogic scale from 0 to 3).Results We included 30 eyes of 29 patients. Mean LT was 4.11 ± 0.64 mm, with a median of 3,89 mm. The Pearson correlation coefficient (PCC) between LT and operative duration was 0.27. The PCC between lens thickness and length of anterior chamber was ‐0.32. The PCC between LT and BCVA at the 7th day after surgery was ‐0.53. Two groups were defined: group 1 with LT &lt; 3.89mm, and group 2 with LT &gt; 3.89mm. Mean length of the anterior chamber were respectively 3.48 and 3.02 mm (p=0.01). Three per operative complications were noted.Conclusion LT in white hyper mature cataract did not seem to be correlated with duration of the surgery. However, it seemed to be inversely correlated with the depth of anterior chamber and with visual acuity at the 7th day.