|Year : 2022 | Volume
| Issue : 5 | Page : 674-681
Comparative study of surgically induced astigmatism in superior and temporal scleral incisions in manual small-incision cataract surgery patients
Abhishek Kumar Tripathi, Ajit Kamalakar Joshi, Hanumant Mandlik
Department of Ophthalmology, Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli, Maharashtra, India
|Date of Submission||10-Aug-2021|
|Date of Decision||27-Aug-2021|
|Date of Acceptance||01-Sep-2021|
|Date of Web Publication||01-Feb-2022|
Dr. Abhishek Kumar Tripathi
Department of Ophthalmology, Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli - 416 416, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The purpose of the study is to evaluate surgically induced corneal astigmatism and visual outcome in patients undergoing small-incision cataract surgery (SICS) by modifying incision site on the basis of type of regular astigmatism. Material and Methods: This is a prospective study including 100 patients, having senile immature cataract, divided in two groups of 50 patients each according to the type of preoperative corneal astigmatism over a period of January 2018 to June 2019. A detailed preoperative evaluation was done including automated refractokeratometry, on the basis of which patients having steeper vertical axis (90° ±30°), i.e., “with the rule” astigmatism placed in Group A and subjected to superior SICS, and those having horizontal steeper axis (150°–180° and 0°–30°), i.e., “against the rule” astigmatism, were placed in Group B and subjected to temporal SICS. All surgeries were performed by a single ophthalmic surgeon with a similar technique of a 6.00 mm superior or temporal scleral straight incision. Surgically induced astigmatism (SIA) was calculated by a computer application SIA calculator version 2.0 on the 45th postoperative day and compared. Results: Present study showed mean SIA was significantly less in the temporal group (1.09 ± 0.42 D) as compared to the superior group (1.38 ± 0.62 D). Conclusion: Modification of incision site in SICS as per preoperative astigmatism produces comparable results to other sophisticated techniques such as phacoemulsification, and hence, it provides an alternative path to attain better visual outcome and reduced SIA with limited resources available in most of the developing countries.
Keywords: Astigmatism, small-incision cataract surgery, superior and temporal incisions
|How to cite this article:|
Tripathi AK, Joshi AK, Mandlik H. Comparative study of surgically induced astigmatism in superior and temporal scleral incisions in manual small-incision cataract surgery patients. Med J DY Patil Vidyapeeth 2022;15:674-81
|How to cite this URL:|
Tripathi AK, Joshi AK, Mandlik H. Comparative study of surgically induced astigmatism in superior and temporal scleral incisions in manual small-incision cataract surgery patients. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Nov 30];15:674-81. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/674/337096
| Introduction|| |
Senile cataract is the most common cause of preventable blindness in developing countries and cataract surgery is the most common ophthalmic surgery being performed to combat this situation. Uneventful cataract surgery with in-the-bag placement of intraocular lens (IOL) gives 100% functional visual recovery if there are no associated comorbid pathologies in the eye.
Over the years, cataract surgery has evolved from intracapsular cataract extraction to extracapsular cataract extraction to phacoemulsification with foldable IOL implantation. Technological advancement occurring in the field of cataract surgery has made it possible.
Miller defined astigmatism as a condition of refraction in which a point of light cannot be made to produce a punctate image upon the retina by a correcting spherical lens.
Surgically induced astigmatism (SIA) is an entity which is studied in detail in recent times. It is a vector quantity having magnitude as well as direction. It is a type of astigmatism which is induced after surgery because of size, site, type of incision, and also placement of the lens.
But in a developing country like India, phacoemulsification remains a distant dream because of its machine dependency, lack of trained surgeons, necessary infrastructure, and nonaffordability.
As an alternative to phacoemulsification, manual small-incision cataract surgery (MSICS) is emerging as the most preferred surgery for the extraction of cataracts, as it is economical compared to phacoemulsification, gives benefits of sutureless surgery due to self-sealing incision, and its short learning curve.
Locating the incision, either superiorly, temporally, or superotemporal, depending on the type of preexisting corneal astigmatism, an additional benefit of further reducing the postoperative SIA can be achieved.
Prasher and Sandhu studied 2316 patients and concluded that more than 40% of patients undergoing cataract surgery have preexisting corneal astigmatism of more than 1.00D and as the age advances, there is a shift from “With the rule” (WTR) to “Against the rule” (ATR) type of astigmatism.
Most elderly cataractous patients have preoperative ATR astigmatism and it is advantageous to take a temporal incision which induces WTR astigmatism. Superior incision is advantageous if only the patient is having preoperative WTR astigmatism.
However, superior incisions aggravate preexisting ATR astigmatism, as most of the elderly patients have “ATR” astigmatism.
Superior or temporal incisions are placed in study patients based on their preexisting corneal astigmatism, namely WTR and ATR and the amount of postoperative SIA induced by the respective incisions is compared and analyzed.
The present study will help in the reduction of SIA, an important cause of poor postoperative vision even after uneventful surgery.
| Materials and Methods|| |
The present study was a prospective, observational, longitudinal hospital-based study which was conducted on 100 eyes of 100 patients with senile immature cataract who were divided into two groups, 50 in each group, on the basis of type of astigmatism subjected to manual small-incision cataract under local anesthesia in a teaching hospital between January 2018 and June 2019.
Written and informed consent was obtained from all the patients. Approval from Institutional Ethical Committee was obtained to conduct the study.(BVDUMCandH/Sangli/IEC/2017-2018/222). All patients were followed up for a period of 45 postoperative days.
The patients having nuclear sclerosis Grade III, cortical and sub-capsular type of senile cataract within the age group of 40–90 years with clinically normal cornea, and preoperative keratometric astigmatism of 1.5D or less were included in the study.
Patients having nuclear sclerosis Grade IV and mature cataract, previous ocular surgeries, corneal degeneration/dystrophies/opacities, scleral diseases and connective tissue disorders, chronic glaucoma, who are unable to co-operate for pre- and postoperatives keratometry, traumatic and pediatric cataract, pseudo-exfoliation, and macular degeneration were excluded from the study.
All study patients were admitted 1 day before surgery. A detailed history of ocular symptoms, any prior ocular surgery, and drug history was taken. With the help of automated refractokeratometry, keratometry readings were calculated on the basis of which patients having steeper vertical axis (90° ±30°), i.e., “WTR” astigmatism placed in Group A and subjected to superior SICS, and those having horizontal steeper axis (150°–180° and 0°–30°), i.e., “ATR” astigmatism, were placed in Group B and subjected to temporal SICS. Fifty eyes of 50 patients each were included in both the groups.
Visual acuity was evaluated by Snellens's chart. Goldmann's applanation tonometry was used to assess intraocular pressure and detailed anterior segment and posterior segment evaluation by 90 D lens was done by slit-lamp biomicroscopy to rule out corneal and retinal pathologies and nuclear sclerosis was graded on the basis of “Oxford Clinical Cataract Classification and Grading System” after dilation of pupil with tropicamide (0.8%) and phenylephrine (5%) eye drops instilled in the lower fornix.
All 100 patients underwent immersion A-scan USG biometry for calculation of axial power and Sanders–Retzlaff–Kraff/Theoretical formula for IOL power calculation. Preoperatively, written and informed consent was obtained and xylocaine sensitivity was done. Blood sugar, human immunodeficiency virus test, hepatitis b test, urine routine, and microscopic examination was done. All patients were started with ofloxacin (0.3%) and flurbiprofen (0.03%) eye drops 1 day prior to surgery and pupils were dilated with tropicamide (0.8%) and phenylephrine (5%) eye drops on the day of surgery. Peribulbar anesthesia with a combination of drugs, namely 3 ml of 2% xylocaine with adrenaline (1:200000), injection hyaluronidase (1500 International Units), and 1 ml (mL) 0.5% bupivacaine was given.
All surgeries were performed by a single ophthalmic surgeon with a similar technique of 6.00 mm superior or temporal scleral straight incision.
Superior small-incision cataract surgery
After peribulbar block, periocular area was painted with 10% povidone–iodine solution and draping was done. After placing universal eye speculum, superior rectus suture, i.e., bridle suture, was taken to stabilize the globe. Fornix-based conjunctival peritomy was done from 10 to 2 O' clock to expose the sclera. Straight incision of 6.00 mm was taken, 1.5 mm behind the limbus with the help of 15 No. blade. Sclerocorneal tunnel was made with a beveled up crescent blade up to 1.00 mm inside the clear cornea. With the help of 15 degree side port blade, side port was made at 9 O'clock. Through the side port, trypan blue dye was injected into anterior chamber to stain the anterior capsule of lens and washed after 20 s.
A disposable 26 no. needle was used as cystitome by bending it, 90° at the edge and 45° at the base. With the help of cystitome, through the side port, continuous curvilinear capsulorhexis of 5.5 mm to 6 mm was made and anterior chamber entry was done with 3.2 mm keratome from sclerocorneal tunnel which extends the inner lip of the wound to facilitate nucleus delivery. Hydrodissection was done by 30 gauge cannula and nucleus was prolapsed in anterior chamber and removed by visco-expression.
Rest of the cortical matter was removed by Simcoe's 2-way irrigation and aspiration cannula and 6.00 mm optic size rigid single piece polymethyl methacrylate lens was placed in a capsular bag. After placing the lens, all the remaining visco-elastic material was removed by Simcoe's cannula. 0.3 ml of preservative-free moxifloxacin (150 mcg/0.1 ml) was injected into the anterior chamber and side port was hydrated. Conjuctival flap was approximated and subconjunctival injection containing gentamycin (5 mg in 0.5 mL) and dexamethasone (1 mg in 0.5 mL) was given. Eye was patched after the application of chloramphenicol (10 mg per gram) ointment.
Temporal small-incision cataract surgery
In temporal incision cataract surgery, the surgeon has to sit on the corresponding side of the patient in comparison to the head end in superior SICS, and accordingly, microscope should also be adjusted. Superior rectus suture, i.e., bridle suture was not taken in any of the cases of temporal SICS.
Fornix-based conjuctival peritomy was done from 7 to 11 o'clock in the right eye and 12-4 O' clock in the left eye to expose the sclera and straight incision of 6.00 mm was taken, 1.5 mm behind the limbus. Sclerocorneal tunnel was made in the same way as for superior incision, but lamellar dissection into cornea should be more anterior to get a better valve effect of self-sealing incision. Side port was shifted to 6 o'clock position. Rest all the steps in temporal incision were same as that of superior incision.
Patients were prescribed with a combination of steroid (prednisolone 1%) and antibiotic (moxifloxacin 0.5%) eye drops and tapered weekly. Postoperatively, on each follow-up, i.e., 1st day, 7th day, and on 45th day, detailed anterior and posterior segment evaluation, uncorrected visual acuity (UCVA), and automated keratometry readings were evaluated. On 45th postoperative day, patients UCVA, best-corrected visual acuity (BCVA), and automated keratometry readings were taken and on the basis of which SIA was calculated by SIA calculator version 2.0. The mean of SIA in both groups was calculated and compared.
Data entry in SIA calculator version 2.0
SIA calculator version 2.0 is an Excel sheet-based application in which entry of preoperative keratometry readings in the form of Kh, i.e., keratometry reading of horizontal axis and Kv, i.e., keratometry reading of vertical axis along with their axis in one column is done. Adjacent to it, postoperative keratometry in a similar form should be entered to get the desired SIA with its axis.
50 entries were done in the superior group and temporal group each and mean SIA was calculated and compared.
Data were statistically described in terms of mean (±standard deviation), frequencies, and percentages where appropriate. Unpaired t-test was used to compare mean of different variables in two groups, namely Group A and Group B. A probability value (P value) <0.005 was considered statistically significant. All statistical analyses were done using computer program Microsoft Excel 2007 and SPSS version 22 (Statistical package for the social sciences) IBM version 22, Chicago, Illinois, Unites states, for statistical analysis.
| Results|| |
The study comprised 100 eyes of 100 patients diagnosed to have senile immature cataracts by
PL+PR Hand Movement 1(2%) 0(0%)
CF 1 meter– CF 5.5 meter 10(20%) 9(18%)
6/60-6/24 38(76%) 40(80%)
6/18-6/12 1(2%) 1(2%)
6/9-6/6 0(0%) 0(0%)
total 50(100%) 50(100%)
detailed dilated slit-lamp examination. These 100 eyes of 100 patients were divided into two groups of 50 eyes of 50 patients each, namely Group A (superior incision) and Group B (temporal incision) and followed up on 1st day, 7th day, and 45th day postoperatively.
In the present study, out of total of 100 patients, 51 (51%) were males and 49 (49%) were females. Group A had 26 (52%) male and 24 (48%) female patients and Group B had 25 (50%) male and 25 (50%) female patients who were studied.
In the present study, maximum number of patients were within the age group of 61–70 years, i.e., 22 (44%) and 20 (40%) patients in Group A and B, respectively. Forty-eight years was the minimum age and 86 years was the maximum age out of all 100 patients.
Majority of patients in both groups, i.e., 38 (76%) in Group A and 40 (80%) in Group B, had preoperative BCVA of 6/60–6/24. Ten (20%) patients in Group A and 9 (18%) patients in Group B had BCVA of CF 1 m – CF 5.5 m. Only 1 (2%) patient in Group A had a vision of PL + PR hand movement [Table 1].
In Group A, on 1st postoperative day follow-up, 32 (64%) patients had UCVA of 6/18-6/12 who were decreased to 20 (40%) on day 7 and slightly increased with the addition of one patient on 45th day. Eighteen (36%) patients had UCVA of 6/9-6/6 and increased to 29 (58%) patients on the 45th day. This trend shows that UCVA after each postoperative follow-up became better [Table 2].
|Table 2: Distribution of uncorrected Snellen's visual acuity on each follow.up postoperatively in Group A|
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In Group B, on 1st postoperative day follow-up, 21 (42%) patients had UCVA of 6/18–6/12 who were decreased to 17 (34%) patients on 45th day follow-up and 29 (58%) patients had UCVA of 6/9–6/6 who were increased to 33 (66%) patients on 45th day follow-up. This trend is in favor of better visual acuity on each follow-up in Group B as compared to Group A [Table 3].
|Table 3: Distribution of uncorrected Snellen's visual acuity on each follow.up postoperatively in Group B|
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On 45th day, temporal group patients had better UCVA when compared to the superior group patients [Table 4].
|Table 4: Comparison of uncorrected Snellen's visual acuity at postoperative 45th day|
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[Table 5] shows that temporal group patients had better BCVA in comparison to superior group patients. Only 1 patient in Group A had BCVA of 6/12 which was attributed to macular edema due to intraoperative complication of posterior capsular rupture.
|Table 5: Comparison of best Snellen's visual acuity at postoperative 45th day|
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In Group A, 2 (4%) patients developed button holing during surgery as compared to 1 (2%) patient in Group B which was managed appropriately without suturing. One (2%) patient in Group A had a posterior capsular rupture with vitreous prolapse. Iris prolapse and hyphema occurred in 1 (2%) patient in Group A as compared to Group B having Iris prolapse in 3 (6%) patients [Table 6].
Mean preoperative astigmatism in Group A and B was 0.79 ± 0.30 D and 0.90 ± 0.32 D, respectively. Mean postoperative astigmatism in Group A was 0.80 ± 0.31 D and 0.57 ± 0.27 D in Group B with the difference of 0.23 ± 0.3 D. Mean SIA in Group A (1.38 ± 0.62 D) was larger than Group B (1.09 ± 0.42 D) [Table 7] and [Figure 1], [Figure 2].
| Discussion|| |
Sutureless MSICS is considered a good alternative to phacoemulsification as it gives comparable results in terms of visual outcome and at lower expenses.
The rate of astigmatism is higher in SICS due to larger incision size and to reduce this problem of increased astigmatism, preoperative evaluation of astigmatism plays a vital role and can be reduced by changing the site of incision accordingly.
In the present study, 100 patients having senile immature cataract were studied and equally divided on the basis of type of preoperative astigmatism in two groups, i.e. Group A and Group B
Group A patients were subjected to superior incision, having 26 (52%) male and 24 (48%) female patients against 25 (50%) male and female patients each in Group B subjected to temporal incision. Gokhale and Sawhney in their study included 42 patients of which 24 were males and 18 were females. Sivacharan and Hanumanthrao included 100 cases, out of which 39 were males and 61 were females.
In the present study, 41–90 years of patients were included with a mean age group of 66.34 ± 8.09 in Group A and 65.42 ± 8.20 in Group B. About 40%–42% of patients belong to the age group of 71–80 years. Sivacharan and Hanumanthrao in their study included patients of the age group of 30–80 years.
In the present study [Table 5], 40 patients had BCVA as 6/6, 9 patients had 6/9, and only 1 had 6/12, because of posterior capsular rupture during surgery later leading to macular edema, at 45th postoperative day in superior incision group (Group A) in comparison to temporal incision group (Group B), 43 patients had BCVA of 6/6 and only 7 had BCVA of 6/9, i.e., temporal incision group (Group A) had better BCVA as compared to superior incision group (Group B).
Bellamkonda and Kavya in their study showed that 27 (54%) patients had BCVA in the range of 6/9–6/6 in superior incision group and 29 (58%) patients in temporal incision group, i.e., temporal incision group had better BCVA than superior incision group which is comparable to the present study.
Sharma et al. in their study showed that temporal incision group had slightly better BCVA as compared to superior incision in which 47 patients had BCVA in range of 6/12–6/6 in temporal incision group against 46 patients in superior incision group which is similar to the present study.
In the present study [Table 6], posterior capsular rupture with vitreous prolapse occurred in 1 (2%) patient of Group A which was managed by automated vitrectomy and later placing IOL in the bag, as rupture was small and central, and suturing of tunnel was done with horizontal sutures which do not alter the astigmatic neutrality of the tunnel. One (2%) patient had developed hyphema and 2 (4%) patients developed button holing during surgery in Group A as compared to 1 (2%) patient in Group B developed button holing.
Temporal incision does not require bridle suture leading to nonstabilization of the globe causing difficulty in formation of the sclerocorneal tunnel and delivery of the nucleus, leading to iris prolapse with visco-expression technique because of which Group B had 3 (6%) cases of iris prolapse as compared to 1 (2%) patient in Group A in the present study.
Temporal incision also has increased chances of postoperative endophthalmitis as the wound is exposed to the surroundings and there is a lack of protection from the upper lid, but in the present study, there were no cases developing endophthalmitis during the course of follow-up period.
Khan et al. in their study included 150 eyes of 134 patients and described various complications related with MSICS and resulted to have 17 (11.3%) cases as hyphema and 5 (3.3%) cases as posterior capsular rupture during surgery, as compared to the present study, only 1 (2%) patient each developed hyphema and posterior capsular rupture. They had also described cystoid macular edema in one patient same as our study attributing to reduced vision.
Mohan et al. in their study also mentioned complications such as wound leak and iris prolapse, especially if the width of wound is more than 3.5 mm which is similar to the present study.
Gogate et al. encountered posterior capsular rupture in 18 patients out of a total of 358 patients who underwent MSICS cases, i.e., 5.02% as compared to the present study having 2% of cases, showing the reduced rate of complication in the current study.
Maske et al. studied 168 patients and encountered one case of button holing as compared to the present study having three cases of button holing.
In the present study [Table 7], SIA was calculated in both the groups, i.e., superior and temporal groups. SIA in Group A was 1.38 ± 0.62 D as compared to 1.09 ± 0.42 D in Group B (Z score 2.74, P = 0.007) with a difference of 0.29 D and it was statistically significant. This proves that temporal incision is better than superior incision in spite of incision taken on the basis of steepness of cornea, i.e., superior incision in “WTR” astigmatism and temporal incision in “ATR” of astigmatism.
Alam et al. in their study compared superior and temporal incision after dividing patients according to their type of preoperative astigmatism, i.e., steeper vertical axis subjected to superior SICS and horizontal steeper axis subjected to temporal SICS, and concluded that temporal SICS (SIA – 0.70 ± 0.3 D) provides better refraction stabilization and reduced amount of SIA as compared to superior SICS (SIA – 1.45 ± 0.4 D). This study supports the present study.
Dividing the patients into two groups, i.e., superior and temporal incision group preoperatively, on the basis of their amount of astigmatism, makes the present study different and unique from various other studies who were based on the random selection of patients preoperatively, and dividing into two groups which may worsen “ATR” astigmatism if a superior incision is taken and vice versa, which is shown by the study of Makayee et al. in which 100 patients were considered and randomly selected leading to worsening of astigmatism and advocated that in WTR astigmatism superior incision and in ATR astigmatism, temporal SICS should be considered.
Makayee et al. in their study had a mean SIA of 0.95 ± 0.4 D in superior group as against 0.57 ± 0.4 D in temporal group, lesser than the superior group, which advocated the present study.
Gokhale and Sawhney in their study found that the mean SIA in superior group was 1.36 ± 1.03 and 0.40 ± 0.40 in temporal group which was significantly less than the former group and also supports the present study.
Malik et al. in their study found to have 1.45 ± 0.7387 D of SIA in superior group which was much greater than temporal group which had SIA of 0.75 ± 0.4067 D and also supports the present study.
Radwan in his study showed that mean SIA in superior group was −2.05 ± 1.19 D which was larger as compared to 0.46 ± 0.43 D in temporal group which was statistically significant and also advocated the present study.
Magdum et al. in their study showed to have mean SIA of 0.62 ± 0.72 D in temporal group which was lesser than the superior group having 0.95 ± 0.68 D of mean SIA and also supports the present study.
Reddy et al. in their study showed that conventional superior SICS results in a greater amount of “ATR” astigmatism, i.e., 1.92 ± 0.53 D than temporal incisions producing 1.57 ± 0.24 D of “WTR” astigmatism which also supports the present study.
Pawar and Sindal in their study showed that in superior incision, SIA was 1.57 ± 0.651 in comparison to 0.42 ± 0338 in temporal incision which was significantly lesser and similar to the current study.
Limitation of the study
The present study considers a small sample size of 100 patients so there is a need for a large sample size to generalize the results.
Random allocation in two groups would have minimized the bias, but considering the fact that randomization might lead to worsening of preexisting astigmatism in few cases, which was avoided in the present study.
Longer follow-up would be required to assess the complication such as endophthalmitis which are more prone in temporal incision as wound is exposed to the surrounding.
| Conclusion|| |
Surgically induced astigmatism is considered a big hurdle in providing good visual outcome to patients undergoing cataract extraction and its amount mainly depends on site and type of incision. Modification of incision site in SICS as per preoperative astigmatism produces comparable results to other sophisticated technique like phacoemulsification and hence it provides an alternative path to attain better visual outcome and reduced surgically induced astigmatism with limited resources available in most of the Indian set-up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]