Structured extracapsular cataract extraction-intraocular lens microsurgical training: report of a trainee's experience.

AIM: The aim was to report the experience an ophthalmologist gained in a structured intraocular lens (IOL) microsurgery training program for the information and benefit of colleagues in ophthalmology training institutions. MATERIALS AND METHODS: An ophthalmologist was trained in extracapsular cataract extraction (ECCE)-IOL implant in Aravind Eye Hospital (AEH), Madurai, for a period of 8 weeks. Details of patients operated on, procedures observed, and conferences attended were prospectively recorded in a log book. RESULTS: Training was available in conventional ECCE with posterior chamber IOL (ECCE-PCIOL), small incision sutureless cataract surgery, and phacoemulsification. During the period, this trainee observed a total of 1527 cataract extractions, administered 528 retrobulbar and 1047 facial blocks, and also operated on 75 patients. The trainee gained experience and confidence to perform high-quality, low-cost cataract surgery. CONCLUSION: Hands-on experience and competence in quality ECCE-IOL implant microsurgery can be acquired in a short period of time in a high-volume cataract center. Trainees can also be exposed to other techniques of cataract surgery. Ophthalmology training centers with diminishing surgical training opportunities can also benefit from this structured training in a high-volume cataract center like Aravind Eye Hospital.

The Madurai Intraocular Lens Study. I: A randomized clinical trial comparing complications and vision outcomes of intracapsular cataract extraction and extracapsular cataract extraction with posterior chamber intraocular lens.

PURPOSE: The Madurai Intraocular Lens Study (MIOLS) was designed to compare safety, efficacy, and quality of life outcomes after either intracapsular cataract extraction with aphakic glasses (ICCE-AG) or extracapsular cataract extraction with posterior chamber intraocular lens (ECCE/ PC-IOL). METHODS: The Madurai Intraocular Lens Study was a nonmasked randomized controlled clinical trial conducted at a single hospital. Thirty-four hundred patients with age-related cataracts and having a best-corrected visual acuity less than or equal to 20/120 in the better eye were randomly assigned to either of the two cataract operative procedures. The main clinical outcomes were safety (complication rates) and efficacy (best-corrected visual acuity at 1 year equal to or better than 20/40). In addition, a subset of 1,700 trial participants received questionnaires before surgery, at 6 months after surgery, and at 1 year after surgery to measure visual functioning and vision-related quality of life. RESULTS: Details of study design, study organization, clinical and quality of life outcome variables, sample size calculations, patient eligibility criteria and recruitment, randomization and masking, participant flow, adherence to follow-up, quality assurance, and statistical methods are presented. CONCLUSIONS: The Madurai Intraocular Lens Study has sufficient power to detect clinically significant differences between the treatment options. There were no statistically significant differences between the two treatment groups for any of the major study variables at baseline. A high level of quality assurance was maintained throughout the October 1993 to June 1996 study period. The results should be applicable to all settings where the requisite expertise and resources are present.

The initial complication rate of phacoemulsification in India.

PURPOSE: This study was designed to investigate the feasibility of teaching experienced surgeons to perform phacoemulsification in India, a cataract-endemic area. Complications occurring during surgery and the first postoperative day were documented and evaluated. METHODS: During a 1-month period, at the Aravind Eye Hospital in Madurai, India, the first 100 consecutive cataract operations performed by each of three experienced surgeons (a total of 300 cases), using phacoemulsification were prospectively evaluated. Multiple logistic regression was used to identify factors associated with intraoperative and postoperative complications. RESULTS: The mean age of patients was 57.4+/-9.3 years. The median best corrected preoperative visual acuity was 20/80. Mean surgical and phacoemulsification times were 15.8+/-3.7 minutes and 2.2+/-1.5 minutes, respectively. Complications occurred in 65 (21.7%) eyes. The most common was a rent in the posterior capsule, occurring in 40 (13.3%) eyes. There were significant variations in complication rate and in surgical time among the surgeons. The risk of experiencing a complication decreased as the number of phacoemulsifications performed increased. An increased risk of complications was associated with worse preoperative visual acuity and increasing patient age. CONCLUSIONS: With each successive case, the chances of experiencing a complication decreased 1%. Acceptable results were obtained within 1 month of performing the first phacoemulsification.

Attacking the backlog of India's curable blind. The Aravind Eye Hospital model.

The number of individuals in developing nations with preventable blindness from cataract and other disorders is increasing. New programs incorporating local customs and efficiently using available resources must be created to prevent the escalation of blindness and to rehabilitate patients already disabled with cataracts. We describe a system of high-quality, high-volume, cost-effective cataract surgery, using screening eye camps and a resident hospital. This has enabled us to provide efficient low-cost cataract surgery and overcome barriers of adequate eye care in southern India. We have been successful in locating patients with treatable eye problems, educating them about the availability of ophthalmic care, and providing free eye care. Our structure stresses the following: community involvement, identification of individuals most likely to benefit from screening, efficient utilization of both medical and paramedical personnel, and a streamlined approach to screening patients. This system may be capable of modification for use in other developing areas to decrease the backlog of cataract blindness.

Intraocular lens implantation in rural India.

We performed 379 extracapsular cataract surgeries with implantation of intraocular lenses (IOLs) in a public eye camp in Ganeshpuri, India (50 miles north of Bombay). Ninety percent (341) of the patients returned for follow up. At 8 weeks postoperatively, 48% of the patients had a visual acuity of 6/18 or better uncorrected; with correction, this figure rises to 71.5%. In general, surgical complications were neither severe nor frequent. More serious difficulties were associated with measuring initial IOL power, obtaining refractive data (including astigmatism), follow up of astigmatism (suture cutting), posterior capsule opacification, and associated preoperative pathology. On the basis of our data, we believe that IOL implantation in public eye camps, under controlled conditions of asepsis and with appropriate instrumentation, is a safe and effective way to provide visual rehabilitation to the rural populations of third-world countries.

Posterior capsule tears during extracapsular cataract surgery in India.

We determined the incidence in a developing nation of posterior capsule rupture during planned extracapsular cataract surgery and insertion of a posterior chamber intraocular lens. The results, in part, determine whether this complication limits the widespread utility of this procedure in developing nations. We retrospectively reviewed charts of all patients undergoing planned extracapsular cataract surgery during a 6-month period; all patients received surgery as inpatients at the Aravind Eye Hospital, Madurai, India, and all were southern Indians. We tried to exclude most patients with prior ocular diseases associated with loss of zonular or posterior capsule integrity. One eye of all eligible patients was included. Extra-capsular cataract surgery was performed using manual irrigation and aspiration with the insertion of a posterior chamber intraocular lens. In this study, we evaluated the ability to maintain an intact posterior capsule with the insertion of a posterior chamber intraocular lens during surgery. Of 898 eyes operated on, 15 (1.7%) developed rents in the posterior capsule, and seven of these had vitreous in the anterior chamber. Nine of the 15 rents were in eyes with either traumatic or hypermature lenses. We conclude that even in a developing nation where many cataracts are mature, hypermature, or traumatic, extracapsular cataract surgery with the insertion of a posterior chamber intraocular lens is technically feasible if surgeons are skilled and experienced.

Analysis of complications in 1000 cases of posterior chamber intra ocular lens implantation.

Analysis of complications in 1000 cases of primary posterior chamber intraocular lens implantation done, during a period of one year was undertaken for the study. The cases included uncomplicated as well as those with various associated conditions like diabetes, traumatic cataracts, complicated cataracts, myopia and developmental cataracts. The important postoperative complications were uveitis (9%), endophthalmitis (0.5%), malposition of IOL (2.8%) and cystoid macular edema (0.3%). Posterior capsule opacification was seen in 11.5% of cases and was treated by YAG laser capsulotomy. More than 80% cases had 6/6-6/12 vision. In our experience posterior chamber IOL implantation has become an extremely successful and satisfying procedure along with the availability of YAG laser facility to manage posterior capsule opacification.

Dacron fixation of an intraocular posterior chamber lens.

Fourteen patients underwent intracapsular cataract extraction and intraocular lens implantation using a posterior chamber lens fixated with Dacron. IOL implantation was uncomplicated, and there was no vitreous loss duirng surgery. IOL fixation occurred within five to eight days after surgery, and all but one pupil could be dilated without lens dislocation. This patient had received atropine drops inadvertently after surgery. Fluorescein angioscopy did not demonstrate cystoid macular edema in the 11 patients who were available for examination and who did not have pre-existing macular disease.