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      Comparison of surgically induced astigmatism between horizontal and X-pattern sutures in the scleral tunnel incisions for manual small incision cataract surgery

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          Abstract

          Dear Sir, We read the article titled, “Comparison of surgically induced astigmatism between horizontal and X-pattern sutures in the scleral tunnel incisions for manual small incision cataract surgery” with great interest[1] and would like to draw your attention toward certain extremely relevant points which have not been covered appropriately. Various ways of suturing the scleral tunnel incisions have been described in the literature.[2] The author chose to compare two such methods. However, if the study was aimed at finding the effect of suturing technique, in that case, the site of incision should not have been altered. This has created another variable in the study. There is no information regarding the magnitude of astigmatism for which the incision placement was changed. Temporal incisions are known to induce lesser astigmatism.[3] The technique described by the author is phacosandwich technique initially described by Fry.[4] It is difficult to perform this procedure in 5 mm incision with two instruments entering the anterior chamber. Further, there is no description of the hardness of the nuclei. Softer nuclei mold themselves and can be delivered without multiple instrumentations inside the anterior chamber. The capsular opening mentioned is 5-6 mm. It may not be possible to take out a rock hard brown or black cataract through even 6 mm capsular opening! As surgically induced astigmatism is more for sections more than 6 mm in size, the study would have been more relevant to section size 6 mm or more for applicability to the developing world where rock hard cataracts are extremely common![5] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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          Reduction in astigmatism in manual small incision cataract surgery through change of incision site.

          To compare the astigmatism induced by a superior, supero-temporal and temporal incision in manual small incision cataract surgery. Induced astigmatism was analysed by Cartesian coordinates based analysis, using Holladay's system. Mean astigmatism induced by surgery was 1.28 Dx2.9 degrees for superior incision, 0.20 Dx23.7 degrees for supero-temporal incision and 0.37 Dx90 degrees for temporal incision. The study found that induced astigmatism was lower in the temporal and superotemporal groups compared to that in the superior group.
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            Role of small incision cataract surgery in the Indian scenario

             Ravi Thomas (2009)
            An entire journal issue devoted to small incision cataract surgery (SICS) is testimony to the popularity of the technique. Although the editor probably intended a perspective on manual SICS (MSICS), a brief background might justify my wider viewpoint. Having learnt the technique of MSICS 17 years ago, facilitated by Michael Blumenthal, I learnt the other SICS technique, phacoemulsification, formally from Kenneth Spitzer in 1992. I ensured that both techniques, MSICS (1992) and phacoemulsification (1994), became routine for all residents (and faculty) in my residency program.[1] Accordingly, although I have popularized MSICS around the country, I will take a broader outlook and comment on several aspects of SICS, not just MSICS. Until recently, MSICS was considered as a low-tech, unproven poor cousin to the gold standard phacoemulsification. Several recent articles have compared MSICS to phacoemulsification and demonstrated almost equivalent outcomes.[2–4] The proven advantage of phacoemulsification is a statistically significant benefit in induced astigmatism of about 0.4 diopter (D); the clinical significance of this statistically significant difference is however debatable.[4 5] On the other hand, nucleus drop with phacoemulsification (0.9%) has a higher relative risk compared with MSICS (Thomas R, unpublished data).[6] Moreover, how much ever we may espouse providing the gold standard for the entire cataract population, in reality even if that were desirable, “phacoemulsification for all” (cataracts) in India (or for that matter anywhere) is neither practical nor feasible. The advantages of MSICS as a low-cost “equally effective” technique makes it an alternative, especially in an unequally developed country like ours. It is argued that MSICS is worse for the endothelium, but a formal study showed no difference in endothelial cell loss between MSICS and phacoemulsification.[4] This is however likely related to the technique of MSICS. There are several types of MSICS, some of these being more elegant and sound in principle than others. I am partial to the Blumenthal technique of MSICS because of the philosophy of the technique as well as that of the anterior chamber maintainer (ACM) integral to this method.[5] The ACM keeps the chamber formed (and endothelium protected) during all the steps of the surgery; other MSICS techniques are unlikely to be equivalent in this respect. The ACM also makes cortex aspiration easier and safer; and if an aspirating cannula is used on a syringe without the plunger, capsule vacuuming can be safely performed without expensive “cap-vac” software. What's more, the ACM converts cataract surgery into an “egress” system, much like vitrectomy (a procedure with a low endophthalmitis rate). It is my bias that such an “egress” system decreases the endophthalmitis rate in cataract surgery too. In fact, I have always used the ACM for phacoemulsification too. It especially makes teaching very much easier and safer, permitting focus on the “phaco” steps rather than things like foot positions.[1] Moreover, the ACM continues to cleave planes created by hydrodissection (even if incomplete). Also, the aspirated fluid is replaced immediately, obviating reliance on expensive software to decrease fluctuations and surges: it literally converts a low-end phacoemulsification machine into a high-end model. Finally, if one wants to learn microincision cataract surgery, an ACM allows that almost without a learning curve.[7] There are those who argue vehemently for MSICS, while others perceive phacoemulsification as the only way. Is there a reason for “phaco” surgeons to learn MSICS too? 100% phacoemulsification (like 100% anything else) is not possible. Even the most experienced phaco surgeons need to “bail out” sometimes, even if it is only due to machine failure. The published literature from India documents this occurrence as 3.7%, about one in 25.[8] Phacoemulsification converted to an unplanned standard extracapsular (ECLX) surgery is worse than a planned ECLX; conversion to MSICS, usually utilizing the same wound, provides better outcomes. Surely, we do not espouse the training of surgeons in phacoemulsification only, as is the current trend in developed countries. Such a surgeon “bailing out” of phacoemulsification would be “bailing out” into tiger country, without a parachute. Similarly, there are reasons for MSICS advocates to learn phacoemulsification. Many patients demand phacoemulsification and are willing to pay more for it, permitting sustainability, in all settings. Even if we strongly believe a particular case is better suited for MSICS, our decision is more likely to be accepted if made from the position of skill in both methods. Rather than supporting only phacoemulsification courses, industry too might be advised to take the broader view and sponsor teaching of cataract surgery per se, including MSICS. After all, those who learn MSICS today are the ones who will want to learn phacoemulsification tomorrow; they are tomorrow's market. The only skills left to acquire will be the actual “phaco” steps, which MSICS surgeons can attain more easily. Therefore, MSICS is really not so much an “alternative” but can be an additional technique in our armamentarium. This armamentarium also includes the standard ECLX as well as the now-forgotten intracapsular surgery. Each technique is used according to the case encountered, the setting, as well as the surgeon's skill and comfort level. A (now rare) hypermature, subluxated lens suspended by only a quadrant of zonules might require intracapsular surgery; alternatively, there is a MSICS technique to glide such a nucleus out too, if the surgeon were comfortable with that. Others may have the skill to perform phacoemulsification in such a case: as long as it does not cost much (which it does) and is not much more likely to involve a vitreoretinal intervention (which it is), because the end result is unlikely to be different. I feel that this issue of the journal on MSICS would have benefited from an article on the teaching of surgical skills and techniques. There are some basic requirements for the transfer of cataract surgical skills: “one-on-one” teaching by an experienced surgeon using high-quality microscopes (with beam-splitters and assistant scopes), as well as instrumentation (and attitude) to manage complications in the most modern manner; the goal is to obtain the best outcome possible under the teaching circumstances.[9] Anything less is a travesty. Although I learnt MSICS unsupervised (because there was no alternative and it was essentially an extension of ECLX), phacoemulsification, was an entirely different technique that I considered unsafe to learn without expert help.[10] The accompanying editorial recommends the model that we were using 15 years ago, wherein the surgeon was taught in his own environment.[11] In this day and age, with the abundance of SICS courses and trained surgeons, there is really no excuse for unsupervised learning of a potentially dangerous technique like phacoemulsification (or for that matter, MSICS), while placing the patient at (avoidable) risk. Still worse is to be instructed in phacoemulsification by an industry engineer, no doubt skilled in machine nuances and armed with the theoretical knowledge of the procedure, but without the ability to safely train an ophthalmologist. Industry must forbid their engineers from such practice. Actually, the profusion of SICS courses is a sad testimony to the state of our residency programs. Surely, the next generation of ophthalmologists should at least be adequately trained in modern cataract surgery and not have to seek courses or fellowships to achieve this. Modern cataract surgery does not mean just the steps of the surgery. Residents will do whatever they observe their teachers do. If they are exposed to shoddy routines, like not scrubbing between cases, sharing of instruments, and general lack of respect for sterile operating room procedures (all of which constitute an unfortunate, reckless attitude), whether in the setting of residency programs, camps, or SICS courses, it will only serve to spawn and reinforce bad habits. The process will ruin our generation next and place their patients at risk. We are already witnessing the negative impact. It seems that some colleagues do not sterilize the phaco tips (let alone hand pieces) between cases. With the risk of not just endophthalmitis, but in these days, HIV and hepatitis B too, this practice is extremely irresponsible and worse than negligence. Let us be reasonable. If you want to perform a high-tech technique like phacoemulsification, please understand that the machine, handpieces, disposables, and the procedure are going to be relatively expensive. Accept it. Cutting costs on sterilization and safety is not the answer to the perceived need for high volumes, not with any technique. If economization is required, economize elsewhere, or use a procedure like MSICS that does not require expensive instrumentation, and that does not mean that such appalling shortcuts are permissible with the cheaper MSICS. Industry too should also discharge their responsibility (and avoid potential problems for themselves) by proactively educating their customers about sterilization requirements for their machines and accessories. To conclude, there is a welcome trend towards SICS in our country. Both MSICS and the “other” SICS have a place in our armamentarium and are complementary, and both are here to stay. Supervised, responsible teaching of SICS techniques is the need of the hour, which is the primary responsibility of residency programs; courses and fellowships, although important, are “band-aid” measures that can do only so much.
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              Comparison of surgically induced astigmatism between horizontal and X-pattern sutures in the scleral tunnel incisions for manual small incision cataract surgery

              Background: Two types of popular scleral tunnel sutures in the manual small incision cataract surgery (MSICS) are horizontal and X-pattern sutures. Surgically induced corneal astigmatism (SIA) is a useful indicator of the suturing effect. Aims: To compare SIA between horizontal and X-pattern sutures in the scleral tunnel incisions for MSICS. Design: Prospective, nonrandomized comparative trial. Materials and Methods: After superior scleral tunnel incision and capsulorhexis, the nucleus was prolapsed into the anterior chamber and delivered. The wound was sutured with either horizontal or X-pattern suture. The simulated keratometry values were derived from the corneal topography preoperatively and 1.5 and 3 months postoperatively. Statistical Analysis: The SIA was calculated by Cartesian coordinates based analysis. Results: Sixty-four patients (32 patients in each group) were included in the study. In the horizontal suture group, the SIA centroid values at 1.5 and 3 months after the surgery were 0.87 × 1° and 1.11 × 180°, respectively, showing induction of against-the-rule astigmatism. In the X-pattern suture group, the SIA centroid values at 1.5 and 3 months after the surgery were 0.61 × 97° and 0.66 × 92°, respectively, showing induction of mild with-the-rule astigmatism. The difference between the amount of SIA at 1.5 and 3 months after surgery was small. Conclusion: In the MSICS, the X-pattern sutures were preferred to the horizontal sutures in the patients without significant preoperative steepening in line with the central meridian of the incision. In the cases with significant preoperative steepening, sutureless surgery or horizontal sutures were preferred. Corneal astigmatism in the patients undergoing MSICS was stable at 1.5 months after the surgery.
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                Author and article information

                Journal
                Indian J Ophthalmol
                Indian J Ophthalmol
                IJO
                Indian Journal of Ophthalmology
                Medknow Publications & Media Pvt Ltd (India )
                0301-4738
                1998-3689
                April 2016
                : 64
                : 4
                : 328
                Affiliations
                Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
                [1 ]Department of Ophthalmology, Subharti Medical College, Meerut, Uttar Pradesh, India
                Author notes
                Correspondence to: Dr. Ruchi Goel, EC 400, Maya Enclave, Hari Nagar, New Delhi - 110 064, India. E-mail: gruchi1@ 123456rediffmail.com
                Article
                IJO-64-328
                10.4103/0301-4738.182953
                4901856
                27221690
                Copyright: © Indian Journal of Ophthalmology

                This is an open access article distributed under the terms of the Creative Commons Attribution NonCommercial ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non commercially, as long as the author is credited and the new creations are licensed under the identical terms.

                Categories
                Letter to the Editor

                Ophthalmology & Optometry

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