EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/115557
56 EW CATARACT March 2013 Cataract editor's corner of the world Is extracap still necessary? by Michelle Dalton EyeWorld Contributing Writer With all the technologies available to surgeons, is there still a place for extracap procedures? I n the U.S., it is often stated that "bigger is better"—supersized drinks, fries, and cars. However, bigger doesn't necessarily mean better in ophthalmology. In cataract surgery, the trend has been for smaller and smaller incisions. Historically, ophthalmologists were trained to perform manual large incision cataract surgery (ECCE). After achieving competence in manual cataract surgery, the resident was then transitioned to perform small incision phacoemulsification. The skills that were acquired during the manual surgery, specifically handling sclera/ conjunctiva and suturing, were considered important tools for future surgeries. Additionally, if a complication were to occur during phacoemulsification surgery, the incision could be enlarged for a safer delivery of the lens nucleus. As phacoemulsification surgery has become the dominant method in developed nations, the indications for manual cataract surgery have decreased. In a recent study, it was found that many residency programs have stopped teaching manual ECCE even though the far majority of cataract surgeons believe that ECCE is still a relevant procedure both internationally and domestically.2 Bonnie An Henderson, M.D., cataract editor W hile no one will argue the safety or efficacy of phacoemulsification, the need for surgeons to perform extracapsular cataract extraction today is more controversial. In manual small incision cataract surgery (MSICS) incisions are around 6-7 mm, and in traditional extracapsular cataract extraction (ECCE) incisions are closer to 11 or 12 mm. "The important thing to remember about small incision ECCE is that a properly constructed incision will cause very little astigmatism and often will self-seal," said Thomas A. Oetting, M.D., professor of clinical ophthalmology, University of Iowa, chief of eye service, and deputy director of surgery service, VAMC Iowa City. Dr. Oetting said he's "very low" on his learning curve with small incision extracap (of the 10,000+ cataract surgeries he's performed he guessed fewer than 10 had been small incision ECCE), so he sutures his wounds. Jeff Pettey, M.D., assistant clinical professor of ophthalmology, Department of Ophthalmology and Visual Sciences, University of Utah, and in practice, John A. Moran Eye Center, Salt Lake City, is an advocate of small incision ECCE simply because surgeons need to have that skill should something go awry with the phaco machine. "It's nice to be able to convert to a manual procedure, but in the developing world, the sheer volume and cost is so great that having a technique like small incision cataract surgery with comparable outcomes to phaco is imperative," Dr. Pettey said. In small incision extracap, "there is no ultrasound energy being released inside the eye," Dr. Oetting said. "Sanduk Ruit, M.D., published an amazing study1 that randomized patients to modern phaco or small incision extracap in Nepal, with each group of patients receiving care from experienced surgeons. In this well-constructed study, small incision ECCE clearly was better than Planned large incision ECCE phaco in this group of patients with advanced cataract. The post-op vision was a bit better, there were fewer complications, the OR time was about one-half of the phaco procedure, and the cost of the small incision ECCE procedure was less than 1/10 that of the phaco procedure," Dr. Oetting said. "Based on that alone, shouldn't everyone be learning small incision extracap?" Dr. Pettey agreed—at John Moran the attending surgeon (Alan Crandall, M.D.) "could do an intracap, extracap, and everything in between. There's nothing that will come up in surgery he's not prepared to handle, but as a resident I learned 100% entirely on phaco," he said. Between the two procedures, small incision is "superior" to large incision, but residents should be learning all three (including phaco), Dr. Oetting said. "I visited the amazing Aravind Hospital in India, and they teach these procedures so beautifully," he said. "They start with limbus-based large incision extracap, then move to small incision extracap, then move to phaco. The mindset there is extracap is easier. My feeling is that phaco is easier, but I'm biased by having learned that technique first." It's rare when an ECCE is a planned surgery here in the U.S., Source: Thomas A. Oetting, M.D. both said. Very dense cataracts are probably the leading reason to plan an extracap surgery, Dr. Oetting said. "Phaco is clearly considered to be the standard of care in the U.S., which has made it hard for me to perform ECCE just for the purpose of training. However, for dense cataracts especially the small incision ECCE should be considered a viable option." Common procedure outside the U.S. Outside the U.S., however, the mindset is much different, Dr. Pettey said. When he finished his residency about 2.5 years ago, he did so without ever seeing or performing an extracap. He purposely chose an international fellowship to gain experience with small incision extracap and has every intention of ensuring the program at John Moran will emphasize the importance of the procedure when he takes over as residency program director this July. "It's important to teach these techniques; it's just a matter of finding enough really dense cataracts that warrant doing small incision cataract surgery," he said. "I think using internet video and other course work, an experienced surgeon can safely learn the small incision ECCE technique," Dr. Oetting said. For those interested in