Incidence and risk factors for vitreous loss in residents performing manual small-incision cataract surgery

Introduction: Ophthalmology residency programs play a critical role in training surgeons to perform cataract surgery. A fundamental component for developing competency in cataract surgery is undergoing a structured surgical training program. There is an inverse relationship between the number of surgeries performed by a resident and adverse surgical outcomes. Aim: To assess the learning curve of Manual Small Incision Cataract Surgery (MSICS) performed by postgraduate students during their residency tenure by estimating the difficulties encountered and intraoperative and postoperative complications during surgical training. Materials and Methods: A hospital-based cross-sectional study was conducted in the Department of Ophthalmology, Hassan Institute of Medical Sciences (HIMS) Teaching Hospital, Hassan, Karnataka, India, from July 1st 2020 to January 1st 2023. Study included 249 patients undergoing MSICS by three postgraduates, who enrolled in the Master of Surgery (MS) Ophthalmology course and received hands-on training in a wet lab were selected. They performed MSICS in a stepwise manner under the supervision of a trained ophthalmologist. Surgeries were recorded and discussed in surgical audits, and intraoperative and postoperative complications were analysed. The collected data was statistically analysed using descriptive statistics such as frequency and percentage. Results: A total of 249 patients, including 135 (54.2%) females and 114 (45.7%) males, with a mean age of 68.4 years, were included in the study. The majority (47%) of cases were senile immature nuclear sclerotic cataracts grade 3-4. Difficulties encountered during the surgeries were tunnel formation (24.6%), capsulotomy (4.5%), nucleus delivery (21.5%), cortical wash (34.3%), and Intraocular Lens (IOL) insertion (14.8%). Intraoperative complications observed were premature entry (46.3%), roof tear (16.1%), Descemet's membrane detachment (7.3%), iridodialysis (7.3%) and Posterior Capsular Rent (PCR) (22.1%). Postoperative complications included wound gaping (0.4%), anterior chamber reaction (10.8%), corneal oedema (25.4%), striate keratopathy (58%) and raised intraocular pressure (5.1%). Conclusion: The most common difficulty encountered during the first year of residency was tunnel formation, while the most common difficulty encountered during the second and third years was cortical wash. The most common intraoperative complication was premature entry, and the most common postoperative complication was striate keratopathy. Stepwise learning by the resident under continuous monitoring by a consultant lowers complications and gives confidence to postgraduate students.

Senile cataract is the leading cause of blindness and one of the factor in pathogenesis of senile cataract is oxidative stress. Oxidative stress through lipid peroxidation can occur in the first phase of pathogenesis of senile cataract. Malondialdehyde is the secondary product of lipid peroxidation that used as a biomarker of oxidative stress. The aim of this study was to determine the difference of plasma malondialdehyde level between immature and mature senile cataract pastient in Ophtalmology Department of Margono Soekarjo Hospital. This study conducted in Ophtalmology Department of Margono Soekarjo Hospital, Purwokerto, starting in April until May 2015. This was a case control study with 20 subjects, 10 subjects in each group of immature and mature senile cataract. Bivariable analysis was done by using Independent t Test with significance rate p=0,05. The mean level of plasma malondialdehyde were 0,401±0,13μmol/L in immature senile cataract and 0,468±0,12μmol/L in mature senile cataract. Bivariable analysis showed that the difference of plama malondialdehyde between immature senile cataract and mature senile cataract (p>0,05) with p = 0,251 is statistically insignificant. The conclusion was there is no difference of plasma malondialdehyde of immature senile cataract and mature senile cataract patient in Ophtalmology Department of Margono Soekarjo Hospital.

Purpose:The purpose of this study was to evaluate trainee performance across six modules of a virtual reality (VR) simulator.Methods:A retrospective observational study was conducted on 10 manual small-incision cataract surgery (MSICS) trainees who practiced cataract surgery on an MSICS VR simulator for one month. They were assessed in six major steps which included scleral groove, tunnel dissection, keratome entry, capsulorhexis, nucleus delivery, and intraocular lens (IOL) insertion under a trainer’s supervision. The information included in their score metrics was collected, and their overall performance was evaluated.Results:Thirty attempts were evaluated for scleral groove, tunnel dissection, and capsulorhexis and 15 attempts for keratome entry. Candidates had varied results in the dimensional aspects and their rates of complications with a mean satisfactory score of 3.1 ± 4.17, 6.8 ± 5.75, 5.8 ± 7.74, and 1.8 ± 2.57, respectively. Nucleus delivery (n = 5) had more of iris pull and IOL insertion (n = 5) had more of lost IOL as complications but both had a higher satisfactory outcome.Conclusion:A VR simulator is a useful tool for training surgeons before their entry into live surgery. It is an effective method for evaluating objectively the structural characteristics of each phase in MSICS and their associated complications, helping them anticipate it earlier during live surgery by giving them a near real world experience.

Introduction : The main causes of blindness in the world are cataract. Community-based cataract surgery plays an important role in reducing the burden of cataract blindness. Objective : To describe patient’s characteristic and visual impairment before and after community-based cataract surgery. Methods : This is a retrospective descriptive study with secondary data from community-based cataract surgery by the Community Ophthalmology Installation of National Eye Center Cicendo Eye Hospital from January 2019 to December 2020. Visual impairment is divided into four categories based on WHO classification. Result : There were 3890 patients included. Most of patients were aged 60 to 69 years in 1533 people (39,41%). The most common diagnosis was immature senile cataract in 1826 people (46,94%). Most of patients underwent unilateral cataract surgery using Manual Small Incision Cataract Surgery method and implantation of intraocular lens. The most common category of visual impairment in one eye before surgery was blind, in 3714 eyes (95,48%) and one day after surgery was poor outcome, in 2466 eyes (63,39%). The two-eye blindness before surgery were 1492 people (38,35%) and after surgery were 652 people (16,76%). Sight restoration rate was 26,8%. Conclusion : Most of the patients were aged 60-69 years. The most common diagnosis is immature senile cataract. The category of one eye visual impairment before surgery was mostly blind, after surgery was moderate visual impairment. There number of blind patients was decrease from 38,35% before surgery to 16,76% after surgery.

Corneal endothelial cell loss with different techniques of nucleus delivery in Manual Small Incision Cataract Surgery- Randomized Controlled Trial.

In manual small incision cataract surgery (MSICS), the occurrence of intraoperative complications is a recognized concern that can impact both surgical outcomes and patient safety. MSICS is widely practiced as a cost-effective alternative for cataract extraction, especially in resource-limited settings where access to phacoemulsification may be limited. However, it is important to acknowledge that MSICS is not entirely risk-free. Complications during the surgery can arise due to factors such as surgeon experience, surgical technique, instrument handling, and patient-specific anatomical variations. Common complications encountered in MSICS include posterior capsule rupture, corneal burns, iris trauma, wound-related issues, vitreous loss, and anterior chamber hemorrhage. It is crucial for surgeons to have a comprehensive understanding of the background and potential risks associated with these complications. This knowledge allows them to proactively implement preventive strategies, optimize surgical outcomes, and prioritize patient safety during MSICS procedures. Ongoing efforts in the field of cataract surgery aim to improve outcomes by advancing surgical techniques, refining equipment, and enhancing postoperative care. Through research and innovation, the goal is to minimize complications and achieve optimal visual outcomes for individuals undergoing cataract surgery. This video discusses the possible complications and provides practical strategies to minimize the same at each step of the MSICS procedure. The video demonstrates the potential complications that can occur intraoperatively during MSICS and highlights the significance of careful technique and practical strategies for prevention. In resource-poor settings, MSICS is widely used as the predominant technique for cataract surgeries. Despite being a cost-effective alternative, MSICS offers comparable visual outcomes to phacoemulsification with low complication rates. This video emphasizes the importance of proactive measures and careful technique in preventing complications, thereby improving patient safety and outcomes in MSICS. https://youtu.be/hOAMJpC67C0.

Background: Pseudoexfoliation (PXF) is an age related, systemic, elastic fibrillopathy causes serious complications during cataract surgery such as zonular dialysis, capsular rupture and vitreous loss. Aim: To study the profile of eyes with pseudoexfoliation syndrome and outcome after Manual Small Incision Cataract Surgery. Materials and Methods: This was a hospital based, prospective study was conducted at Tertiary Care Hospital between August 2016 to September 2018. PXF was diagnosed on slit lamp examination by the presence of white dandruff like material in anterior segment. Gonioscopy was done to know the status of angles, pigmentation and presence of PXF material. Results: Out of 80 patients with PXF who underwent manual small incision cataract surgery (MSICS), 17 patients had complications. Zonular Dialysis alone was found in 3 eyes (17.65%) and Zonular Dialysis with Vitreous Loss was seen in 4 eyes (23.53%). Only Posterior Capsular Rent (PCR) was found in 2 eyes (11.76%) and PCR with Vitreous Loss was found in 4 eyes (23.53%). Sphincter Tear was noted in 3 eyes (17.65%) and Iridodialysis was seen in one eye (5.88%). Conclusions: Ophthalmologists should focus on the detection of PXF especially considering the risks for intraoperative complications related to PXF. The diagnosis of PXF may also be important in the management of cataract in these patients.

Manual small-incision cataract surgery (MSICS) is a more cost-effective and financially viable option for many settings in the developing world. Excellent effectiveness makes MSICS the most appropriate technique for performing high-volume cataract surgeries, especially in developing countries.[1] Tabin et al. reported that cataract accounts for almost 75% of cases of avoidable blindness in developing countries. With a large amount of avoidable blindness due to cataract prevailing in our country and most of the population not being able to afford phacoemulsification, MSICS has become an important tool for eliminating it.[2] Learning the correct and safe technique of MSICS is of utmost importance to tackle the huge burden of cataract in our country. Endothelial protection during MSICS is critical to maintain the cornea transparent postoperatively. The authors of this review article have given nice tips as to how one can meticulously prevent endothelial cell loss during each step of MSICS surgery. Handling the instruments that are introduced in the anterior chamber is a continuous learning process, so all surgeons at every level of their career should emphasize on improving one’s own technique.[3] The surgical techniques in cataract surgery are evolving toward a safer side in terms of endothelial protection, so one should not hesitate in adapting a new and safer technique. The most common step where the endothelium gets damaged is during nucleus delivery.[4] There are various methods of nucleus delivery. The surgeon should practice that method which is safe in his/her hands. Nowadays various types of cohesive and dispersive ophthalmic viscosurgical devices (OVDs) are produced in our country and they are available at an affordable cost. Appropriate OVDs should be used depending on the type of cataract and associated ocular problems, especially during nucleus delivery and intraocular lens (IOL) implantation. Authors of this review article have mentioned different techniques of use of these OVDs to safe guard the endothelium. Maintaining the anterior chamber all through the surgery is important to minimize the endothelial cell loss in MSICS. Though MSICS has valved and self-sealing incision to maintain the depth of the anterior chamber, the chamber depth may alter during instrumentation and nucleus delivery. So one should take care to maintain the depth of the anterior chamber with the appropriate use of irrigating solutions, OVDs, the correct method of introducing the instruments into the anterior chamber, and proper use of Simcoe cannula.[5] One should also be aware of patient-related factors that alter the depth of the anterior chamber like lid squeezing and positive pressure in obese patients. One should know the safer dose and right technique of using various intraocular drugs because the toxic effect of these drugs on the endothelium can sometimes remain permanent.[6] There is also a need for standardizing the quality of the drugs at the production level; hence, the appropriate authorities should make stringent rules and monitor the drugs produced by various companies in our country.

Cataract is the primary cause of avoidable blindness worldwide, while age-related cataract is the most common andcataract surgery forms the major workload of most ophthalmic units. Manual small incision cataract surgery (MSICS)has become popular in Libya in the last few years. It is significantly faster, less expensive, require less technology andachieves excellent visual outcomes with low complication rates. The aim of the study is to evaluate the safety, complications and outcome of MSICS in the treatment of patients with mature cataract. Data was collected from medicalrecords of 190 eyes of 184 patients with mature cataract that received surgery at Albasar ophthalmology clinic andMisurata central hospital- Misurata-Libya between January 2014 and December 2017. Out of 184 patients 109 werefemales (59.2%) and 75 were males (40.8%). About 74% of the patients were between 51 and 70 years old. Intraoperative difficulties and complications encountered during surgery were improper tunnel construction inform of premature entry in two (1.05%) cases and button holing in one (0.52%) case. Difficulty in nucleus delivery to anteriorchamber 13 (6.8%) cases, pupillary constriction 10 (5.3%) cases, intraoperative hyphema 13 (6.8%) cases, capsulorrhexis extension and posterior capsular tear with vitreous loss 4 (2.1%) cases, iris prolapse 2 (1.05%) cases. Widening of the incision to facilitate nucleus delivery in 19 (10%) cases. The postoperative complications include hyphema 9 (4.7%) cases, transient corneal oedema 42 (22.1%) cases, corneal decompensation one (0.5%) case. Irregularpupil 13 (6.8%) cases, iritis 11 (5.8%) cases and posterior capsule opacification (PCO) 3 (1.6%) cases. The recordedbest corrected visual acuity (BCVA) three months postoperative was good results (visual acuity 6/12 or better), theaverage results (visual acuity between 6/18 and 6/60) and the poor results (visual acuity less than 6/60) were respectively 82.1%, 12.6% and 5.3%. MSICS can be recommended as an efficacious surgical technique with low complications and good visual outcome in treatment of patients with mature cataract.

To examine and improve outcomes of resident-performed manual small incision cataract surgery (MSICS) cases via analysis of visual recovery, intraoperative adverse events, and early postoperative course. Particular focus was directed toward mature cataracts extracted by MSICS. A retrospective review was performed to identify MSICS cases performed by resident surgeons unfamiliar with the technique (initial ten cases) in an academic setting. Preoperative history, intraoperative adverse events, and postoperative course were reviewed. Of 30 cases identified, mean preoperative acuity was 1.8 ± 0.9 logMAR units (Snellen equivalent = 20/1262) improving to 0.20 ± 0.35 logMAR units (20/31) at final follow-up (p < 0.0001). Mean follow-up was 22.1 ± 19.0 days. The most frequent intraoperative adverse events were wound leak requiring intraoperative suturing (33 %), vitreous loss (6.7 %), and capsulorhexis radialization (6.7 %). Transient cornea edema was the most frequent (56.7 %) early postoperative minor complication. Two major complications occurred that required wound revision in one eye and iridoplasty in one eye. Of the 30 eyes undergoing surgery, 19 were noted to have mature cataracts. In this subset, mean acuity was 2.25 ± 0.64 logMAR units (20/3557) improving to 0.28 ± 0.42 logMAR (20/38) at final follow-up (p < 0.0001). Complications were similar in nature and frequency to the entire population in this subgroup. Supervised resident MSICS cataract surgery can result in excellent anatomic and visual outcomes. Appropriate wound construction is a frequently encountered difficulty, so particular attention should be directed to this step by both trainers and trainees.

To compare the intraoperative and immediate postoperative behavior and complications in eyes with pseudoexfoliation (PEX) syndrome with eyes having senile cataract without PEX during cataract surgery using phacoemulsification (PKE). In this prospective study, 68 eyes of 68 patients were divided into two groups: Group 1 (test) comprised 34 eyes with immature senile cataract with PEX and Group 2 (control) included 34 eyes with immature senile cataract without PEX and any coexisting ocular pathology. Phacoemulsification (modern cataract surgery) was performed on both groups through stop and chop technique and comparative analysis of the incidence of intraoperative and immediate postoperative complications was made. There was no significant difference in rates of intraoperative complications between PEX (2.9%) and Control (0%) group. The mean pupil diameter was significantly smaller in Group 1 (p<0.001). No eye in either group had phacodonesis. 58.8% of eyes in Group 1 and 29.4% in Group 2 had a harder cataract (nuclear sclerosis) ≥ grade 3 (p=0.017). PKE was performed in all eyes with cataract in both groups. Intraoperative complication (zonular dialysis (dehiscence) was encountered in only 2.9% (1 case) of eyes with PEX. PC (posterior capsule) tear (rent) with vitreous loss was seen in 2.9% eyes of Group 1 and none in Group 2. Postoperatively, IOP (intraocular pressure) and aqueous flare response were comparable between the groups. Significantly higher inflammatory cell response was observed in Group 1 (p=0.014). BCVA (best corrected visual acuity) using Snellen chart with pinhole on postoperative day1 was significantly better in the control group compared to the group with PEX (p=0.027). Phacoemulsification can be safely performed by experienced hands in cataractous eyes with PEX. The incidence of intraoperative and immediate post-operative complications in eyes with PEX was not significantly different compared to eyes without PEX in our study. Further studies among a larger population are required.

Background: Dilemma of cost effectiveness of manual small incision cataract surgeries (MSICS) in the terms of training and equipment has been widely pondered upon in developing areas. Objective of the study is to compare the manual small incision cataract surgery and extra capsular cataract extraction.Methods: A prospective study was conducted among the IPD patients of the Ophthalmology Department of Khaja Bandanawaz Teaching and General Hospital, Kalaburagi, from June to December 2017. Statistical Analysis was performed using Microsoft Excel 2013, SPSS 23.0 and Chi-square test was performed.Results: Out of the 160 individuals who underwent extra capsular cataract extraction (ECCE), 06 (3.75%), 91 (56.88%) and 63 (39.37%) of the study subjects had poor (5/50), moderate (6/60-6/24) and good (6/18-6/6) visual acuity respectively. Highest incidence was that of lens prolapse (25%) and corneal complications (25%) in ECCE. Among the subjects who underwent MSICS, highest incidence of intra operative complication noticed was that of lens prolapse, iris prolapse and anterior chamber collapse, each at 20%.Conclusions: It was concluded that the restoration of visual acuity was fairly good and uniform in both the procedures. Certain intra operative complications such as lens prolapse, iris prolapse and anterior chamber collapse were noticed in MSICS and capsular flaps and vitreous loss were noticed only in ECCE.

High volume cataract surgery is practised in many eye centres. To investigate whether routine high volume cataract surgery can be performed without compromising the quality of surgery. A retrospective interventional study was carried out at a high volume eye care centre including 368 subjects with cataract operated within 5 randomly selected theatres. Suture-less manual small incision cataract surgery (SICS) with PCIOL was performed in all except nine cases. Of the total, 81.8 % of the patients achieved post-operative uncorrected visual acuity (UCVA) of 6/18 and better by the 4th week. Only 0.3 % had a posterior capsule tear without vitreous loss, 0.5 % posterior capsule tear with vitreous loss and 0.8 % had hyphema. Post-operative examination done at the camp site after Day 30 did not reveal anterior segment complications in any of the patients. Fifteen patients were found to have posterior capsular opacification and had the UCVA between 6/24 - 6/60. Only 12.9 % of the patients had first post operative day complications, which included transient corneal oedema (3.0 %) with less than 10 Descemet folds, transient corneal edema with > 10 Descemet folds (3.6 %), transient corneal edema (4.3 %), shallow anterior chamber (0.3 %) and others like iritis and peaked pupil. Multiple logistic regression analysis showed no significant association between risk factors like age, sex, laterality, pre-operative visual acuity, surgeon, time of surgery and post-operative UCVA. The study results show that high quality cataract surgery can be attained in a high volume setting.

To evaluate changes in macular thickness via-a-vis visual acuity post uncomplicated manual small incision cataract surgery (MSICS) &amp; phacoemulsification surgery Prospective clinical study on 160 patients of uncomplicated immature senile cataract, aged 40-70yrs, patients were randomised into two groups, MSICS &amp; phacoemulsification, by simple 1:1 randomization, who underwent uncomplicated cataract surgery with posterior chamber intraocular lens (PCIOL). Post-operatively, the patients were evaluated for best corrected visual acuity (BCVA) and changes in macular thickness by optical coherence tomography (OCT) at post-op Day 1, 7, 21, 48, and 12 weeks. Paired t-test was used for comparison across follow up. : At 12 weeks post-operative, mean logMAR BCVA was 0.01±0.02 for MSICS group and 0±0.02 for Phacoemulsification group. Macular thickness was not statistically significant (p=0.342) between MSICS group (219.19±17.88µm) and Phacoemlusification group (215.61±16.21µm), at the end of 12 weeks post-operative. Clinically significant macular oedema was not diagnosed in any of the patients at the follow-ups.: Both procedures achieved good post-operative Best Corrected visual acuity without significant differences in BCVA between both the groups at the end of 12 weeks.

Manual Small Incision Cataract Surgery: A Review.