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Sutureless manual cataract procedure may be effective for rural China
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BEIJING — A sutureless, large-incision manual extraction procedure may be the best technique for cataract surgery in rural China, according to Prof. Dennis Lam.
Citing barriers such as cost and lack of infrastructure in rural villages in China, Prof. Lam said there is a need to develop a low-cost, easily managed, reliable cataract surgical procedure that can be taught easily to local surgeons.
“We need to be able to provide quality cataract surgery in an affordable manner close to where people live,” Prof. Lam said here at the Asia-Pacific Association of Cataract & Refractive Surgeons meeting.
“Phaco is too expensive, while small-incision procedures require a highly skilled surgeon that makes the procedure difficult to teach,” he said. “An ideal surgery would be sutureless, safe and effective with little astigmatism, low cost and would be easy to teach and learn.”
He said he believes that sutureless large-incision manual cataract extraction (SLIMCE), a technique that he developed, may be the solution to this problem.
Prof. Lam said conventional wisdom has it that a large incision will induce astigmatism. To date, he said, he has not found that to be true in his results with the SLIMCE technique.
For the procedure Dr. Lam uses either peribulbar or retrobulbar anesthesia. No facial block is needed. He uses a temporal approach.
To perform the technique Prof. Lam said he fixates the globe with 0.12-mm forceps. He then makes an 8-mm incision at 200 µm depth using either a diamond blade or a crescent knife to create a scleral tunnel.
“It’s about 2 mm to the clear cornea, so the tunnel is about 4 mm in length,” he said. “For those with experience creating a small tunnel, it shouldn’t be too difficult to create a large tunnel.”
He then instills two drops of trypan blue dye under air to facilitate capsulorrhexis in hard nuclei.
“You can use a cystotome in vitro or use forceps to complete your capsulorrhexis,” he said.
Prof. Lam said it is important to create a 6-mm capsulorrhexis, “otherwise you may have problems getting the nucleus into the anterior chamber.”
To move the lens from the capsular bag into the anterior chamber, Dr. Lam uses two Sinskey hooks, one placed at the far end of the lens from the incision and the other placed at the near end. While pulling toward the incision from the far end, Prof. Lam also applies downward pressure on the near hook to “tumble” or invert the lens into the anterior chamber.
“We have tried many methods for removing the lens from the bag, and we find this method results in the least zonular stress,” Prof. Lam noted.
To remove the lens through the scleral tunnel, Prof. Lam inserts an anterior chamber maintainer to apply pressure and also applies pressure to the opposite end of the sclera with Utrata forceps to push the lens through the tunnel.
“The important part here is that if you do the tunnel right, the nucleus will not actually hit the endothelium, and by having an anterior chamber maintainer increasing the pressure the nucleus will be pushed toward the tunnel,” Prof. Lam said. “Then you press on the sclera so that the flow of the nucleus will be toward the scleral tunnel.”
He removes the viscoelastic and checks the wound and the tunnel to ensure there are no nuclear fragments or any residual cortical matter.
“At the end of the day we can use cautery to close the conjunctiva without any sutures,” he said.
In Hong Kong, Prof. Lam said, he performed this procedure on 100 consecutive eyes and found the endothelial cell loss to be less than 5%.
“We only lose around 100 to 200 cells on average,” Prof. Lam said.