"Show me the way" - Endoilluminator-assisted manual small-incision cataract surgery in a case of corneal scar with a small pupil.

Cataracts with coexisting corneal opacities due to various causes present a daunting challenge to surgeons. Adding to the plight could be factors like shallow anterior chamber, small pupil and mono-ocular patient. A manual small-incision cataract surgery (MSICS) could be a saviour in such situations. We demonstrate a case of post perforation corneal scar secondary to Hansen's disease with complicated cataract with non-dilating pupil in a bilaterally blind patient. Due to poor visualisation, there could have been difficulties in capsulorrhexsis, cortex aspiration & many other intraoperative manoeuvres, but use of an endo illuminator providing oblique illumination was very useful, resulting in uneventful surgery with good visual outcome. MSCICS, a surgery with minimal instrumentation, short learning curve and comparable results to phacoemulsification is perhaps the preferred procedure, in India, for complicated cataracts with multiple pre-existing pathologies.

Cataract surgery at Marie Adelaide Leprosy Centre Karachi: an audit.

OBJECTIVE: To determine the outcome of cataract surgery in terms of visual results, intra and postoperative complications at Marie Adelaide Leprosy Centre. METHODS: The study was carried out at Marie Adelaide Leprosy Centre Karachi from May 2005 to December 2007. Surgical results of all outpatients operated for cataract from May 2005 to December 2007 were assessed. The data was collected using the CBM guidelines based on WHO monitoring systems for quality monitoring. Patients having uncomplicated cataract were included. Postoperative follow up was done at discharge, 1 week, 4 weeks and after 12 weeks, visual acuity was recorded as good (6/6-6/18), borderline (6/18-6/60) and poor (< 6/60), intraoperative and postoperative complications were also noted. RESULTS: During the study period a total of 1457 patients underwent cataract surgery. There were 826 male patients and 631 female patients, their age ranged from 20 to over 80 years. Preoperatively 1023 (70.2%) patients had poor, 362 (24.8%) patients had borderline while only 73 (5%) patients had good visual acuity while at discharge 962 (66%) patients had good, 392 (26.9%) patients had borderline and 104 (7.1%) patients had poor visual acuity. On an average among all the best corrected visual acuity was good in 97.2%, borderline in 2.2% and poor in 0.6% patients at 1 week, 4 weeks and >12 weeks follow up respectively. A large number of patients, 565 (38.7%) did not turn up after discharge for follow up, presumed reasons were: good vision, unable to return because of socioeconomic reasons, ill health and few of the patients expired. Intraoperative complications seen were posterior capsular rent with vitreous loss 70 (4.8%), zonular dehiscence 3 (0.2%), posterior loss of cortical matter 2 (0.1%) and iris prolapse in 4 (0.2%) cases. Immediate postoperative complication was striate keratopathy 157(10.7%), late were chronic anterior uveitis 3 (0.2%), corneal decompensation 2 (0.1%) choroidal and retinal detachment 1 (0.06%) each, Intraocular Lens (IOL) subluxation 4 (0.2%) and Posterior capsular opacification 40 (2.7%). CONCLUSION: In our study visual outcome achieved was comparable to the standards set by World Health Organization. In complicated cases functional vision can be achieved with timely management.

Intra and post operative complications and visual outcomes following cataract surgery in leprosy patients.

OBJECTIVES: The occurrence of intra and post operative complications was compared in different groups of leprosy patients. The association between post operative and intra operative complications was studied, and how visual outcomes were affected by these complications. We also share our medical management and surgical techniques that might help minimise intra operative complications and improve visual outcomes. DESIGN: A retrospective analysis of 1024 cataract operations in 786 leprosy patients over an 11 year period from 1995 to 2006 at Kothara Community Hospital, a rural hospital belonging to The Leprosy Mission Trust India, located in the Amravati district of Maharashtra. RESULTS: 3.5% of eyes had intra operative complications and 22% of eyes had post operative complications, with no appreciable difference in incidence of intra operative complications in the various groups of patients studied. Post operative uveitis was higher in the MB (3.2%), smear positive (6.5%), UT (6%), eyes with leprosy related ocular disease (6.4%) and lepra reaction (12%) groups. Overall, eyes with leprosy related complications and eyes operated on during lepra reactions had more post operative complications compared to the group without. Visual outcomes for eyes with intra and post operative complications were poorer than the groups without. CONCLUSIONS: Cataract surgery in the hands of a careful and well trained surgeon, who is familiar with ocular leprosy and can modify the surgical technique as necessary, is safe and associated with minimal intra operative and post operative complications.

Cataract surgical coverage and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria.

AIMS: To determine the coverage, outcome, and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria. METHODS: People 30 years and above resident in eight leprosy villages were examined. Cataract blind people were questioned about the reasons they had not been treated. Subjects who had received an operation for cataract were examined to determine the outcome and, where applicable, the causes of poor outcome. RESULTS: 480 people were examined. Cataract was the commonest cause of blindness. The cataract surgical coverage (people) was 39.2% for orthodox surgery and 29.7% for couching. After surgery, visual acuity > or =3/60 had been restored to 82.1% of eyes that had had orthodox surgery, but only 58.6% of eyes that had been couched. Cost was the commonest reason given for not seeking treatment for cataract. CONCLUSIONS: Cataract is the major cause of blindness in this population but cataract surgical needs are currently not being met. There is a need for better collaboration between leprosy control and ophthalmic services, improved education of people affected by leprosy, a commitment to improving orthodox cataract surgery outcomes, and consideration of a possible role for traditional healers as sources of referral for orthodox surgical services.

Visual outcome of extracapsular cataract extraction and intraocular lens replacement in leprosy patients.

The study was carried out in Meshed, Islamic Republic of Iran, from 1998 to 2000 to explore the visual outcome of eye surgery with extracapsular cataract extraction and intraocular lens replacement on 18 leprosy patients (20 eyes). The most common complications of leprosy were madarosis (90%) and partial or total corneal opacity (90%). Visual acuity before surgery ranged from 'light perception' to 1/10, and this improved after surgery to 5/10-8/10 for 55% of patients. Postoperative infection leading to endophthalmitis occurred in only 1 patient and was treated with drugs; this patient's visual acuity remained at 10 cm finger count. Posterior synechia due to chronic uveitis in leprosy was diagnosed in 70% of eyes, obstructed iris in 25%, keratic precipitates in 25% and moderate iris atrophia in 10%.

Intraocular lens implantation in leprosy.

The preoperative, operative and postoperative ocular complications in 48 eyes of 39 leprosy patients who underwent standard extracapsular cataract extraction and posterior chamber intraocular lens implantation, by the same surgeon, were studied retrospectively. Seventeen were male and 22 were female. Thirteen (33%) were paucibacillary (PB) while 26 (67%) were multibacillary (MB) patients. Three patients were smear-positive at the time of surgery. Grade 2 deformity that included claw hands, absorbed fingers, saddle noses and foot drop were present in 64% of the patients. None of the patients had any previous intraocular inflammation although one patient had previously had a Type 1 reaction and 5 patients had previously had Type 2 reactions. Preoperative complications like corneal opacities (3 eyes) and lagophthalmos (5 eyes) were not associated with lower vision postoperatively. No significant operative complications like vitreous loss, endothelial damage or iris tear were encountered, except in one eye where there was a posterior capsular tear. Seventeen eyes (35%) developed uveitis of 3+ or more in the immediate postoperative period, but abated with routine topical steroid eye drops. Six months after surgery 7 out of 47 eyes (15%) had developed posterior capsular opacities. There were no significant differences (p = > 0.05) in the visual acuity outcomes or in ocular complications when MB patients were compared with PB patients. Smear-positive patients were not significantly different from smear-negative patients when postoperative complications were compared. Visual outcomes in the 23 eyes followed up at two years after surgery were 6/18 or higher, except in one eye which had sustained a severe injury one year after surgery. IOLs were found to be safe and beneficial in this series of patients, but a much larger prospective study with matched normal controls is needed to prove the safety and efficacy of IOLs in leprosy patients.

O uso de lentes intra-oculares em pacientes portadores de hanseníase / Use of intraocular lenses in patients with leprosy

Objetivo: Avaliar as alteraçöes oculares decorrentes da cirurgia de catarata com implante de lentes intra-oculares (LIO) em pacientes portadores de mal de Hansen (MH) e compará-las às dos pacientes näo-portadores de Hanseníase. Métodos: Neste estudo, 122 olhos de 80 pacientes portadores de MH e 71 olhos de 71 pacientes näo hansenianos foram submetidos à facectomia extracapsular e/ou à facoemulsificaçäo com implante de LIO e examinados periodicamente durante o pós-operatório. Resultado:Foram constatadas alteraçöes oculares decorrentes da cirurgia e da presença da LIO mais freqüentes no grupo portador de hanseníase.Conclusäo: O uso da LIO em pacientes com hanseníase, mesmo ocorrendo algumas alteraçöes inflamatórias, é indicado devido ao benefício que propicia a esses pacientes em face das mutilaçöes decorrentes da doença.

Cataract in leprosy patients: cataract surgical coverage, barriers to acceptance of surgery, and outcome of surgery in a population based survey in Korea.

BACKGROUND/AIMS: Cataract is the leading cause of blindness in leprosy patients. There is no population based information on the cataract surgical coverage, barriers to use of surgical services, and outcome of surgery in these patients. We sought to determine these measures of cataract programme effectiveness in a cured leprosy population in South Korea. METHODS: The population consisted of residents of six leprosy resettlement villages in central South Korea. All residents were invited to participate in a study of eye disease and interviewed regarding use of surgical services and reasons for not using these services. RESULTS: The cataract surgical coverage in this population was 55.4% when <6/18 was used as the cut off and increased to 78.3% when the cut off was <6/60. Barriers reported by patients included being told by the doctor that the cataract was not mature and a perception by the patient that there was no need for surgery. Among patients who had aphakic surgery, 71% were still blind in the operative eye while among patients who had pseudophakic surgery, 14% were still blind (presenting vision). Blindness in pseudophakic patients could be reduced to 3% with spectacle correction. CONCLUSION: Cataract prevalence in leprosy patients will increase as life expectancy continues to increase. Leprosy control programmes will need to develop activities aimed at reducing the burden of cataract. Recommendations include establishing collaborative agreements with ophthalmological services to provide high quality IOL surgery to these patients, training of health staff to identify and refer patients in need of surgery, monitoring the uptake of cataract surgery among patients needing services, and monitoring the outcome of surgery to improve refractive outcome.

Extracapsular cataract extraction and intraocular lens implantation in leprosy patients: visual outcome and complications.

In Belo Horizonte, Brazil, 70 eyes of 53 leprosy patients had extracapsular cataract extraction and intraocular lens implantation done during a period of four years. The authors analyzed the outcome regarding restoration of vision and complications after this procedure. The visual acuity improved in 92.9% of the eyes and in 65.7% the acuity had improved by four lines or more on the Snellen chart. The post-operative complications could not be associated only to leprosy infiltration; in any case, they were not too serious and could be controlled.

The pattern of cataract and the postoperative outcome of cataract extraction in Ethiopian leprosy patients as compared to nonleprosy patients.

Cataract is a blinding disease occurring all over the world. One of the causes of cataract is leprosy. Sixty leprosy and 100 nonleprosy patients were assessed and underwent intracapsular cataract extraction. Leprosy patients with cataract were much younger than nonleprosy patients. The leprosy group had a significantly higher rate of complications and this was seen more in paucibacillary cases. There was a higher rate of visual disability in the leprosy group than in the nonleprosy group. Cataract was seen in younger patients in the leprosy group. This raised the possibility of leprosy being the cause of the cataract. The leprosy group consisted mostly of multibacillary cases, however unlike in other studies the rate of complications tended to be higher in the paucibacillary group. There were no preoperative findings that correlated with a low postoperative intraocular pressure.

Cataract surgery in a leprosy population in Liberia.

In Liberia, 43 eyes of 30 patients with ocular leprosy underwent cataract extraction; 33 eyes had extracapsular cataract extraction (ECCE) and 10 eyes had intracapsular cataract extraction (ICCE). ICCE was performed in eyes with poor visualization of the anterior chamber. In 95% of the eyes, the postoperative vision improved by 2 Snellen lines or more, but functional visual acuity (better than 20/200) was achieved in only 65% (82% post-ECCE and 10% post-ICCE). Fewer postoperative complications were observed after ECCE. These findings may have been related to less ocular involvement by leprosy preoperatively. ECCE should be attempted when the visualization of the anterior chamber is fair.

Points of action in the campaign against blindness in developing countries.

This article provides a survey of the problems of prevention of blindness in developing countries. The World Health Organization estimates that 31 million people are blind and 15 million people partially-sighted. The main cause of blindness is cataract. Other causes are trachoma, glaucoma, xerophthalmia, river blindness, corneal scars and leprosy. Prevention or treatment of these causes is possible in more than 80% of cases. The number of blind persons, however, is still increasing due to the increase in population and the immense shortage of all kinds of ophthalmological equipment and personnel. An effective strategy for the prevention of blindness in developing countries should focus on: more cheap cataract operations, increasing teaching facilities for ophthalmic personnel, integration of ophthalmic care into the general health system and the promotion of blindness prevention in political organizations.

Cataract surgery on leprosy patients.

All patients who had cataract surgery at the Schieffelin Leprosy Research and Training Centre, Karigiri, India, between January 1979 and April 1985 were studied to find out the outcome of that surgery. These patients included 291 leprosy cases and 89 nonleprosy cases. Postoperative complications were slightly higher among leprosy patients compared to the nonleprosy cases. Visual recovery was marred by preoperative corneal opacities in some of the leprosy patients. Eyes with chronic insidious type of iridocyclitis did not produce any devastating results postoperatively. Patients whose skin smears were still positive for leprosy bacilli did not show any major complication. All leprosy patients should be offered the benefit of cataract surgery for restoring sight because blindness in leprosy would mean a double handicap if they are already suffering from insensitive, deformed hands and feet.