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EW NEWS & OPINION 26 How manual fix currently compares to phacoemulsification W hile for most cataract practitioners pha- coemulsification re- mains the name of the game, manual ex- tracapsular surgery continues to be an important skill for surgeons to have, finds Suzann Y. Pershing, M.D., clinical instructor, Stanford University, Stanford, Calif. In a re- view piece published in the Novem- ber 2010 issue of Current Opinions in Ophthalmology, investigators found that results with the procedure ri- valed phacoemulsification in some cases. For the study, investigators culled recent literature. "Some of the references were a bit historic just for background, but it was mainly a review from the past year," Dr. Pershing said. Extracap today Prevalence of extracapsular surgery use varies depending on the setting. "In India it is extremely prevalent," Dr. Pershing said. "Nepal and some areas in South America have also ad- dressed it; however, the industrial- ized countries are the ones that have primarily embraced phacoemulsifi- cation." For surgeons in some of these non-industrialized areas it's not an issue of having access to a phaco machine but of having access to one that is in working order. "They may have the phaco machine, but if no one knows how to fix it or if there isn't a rep available to bring in a new part, it's not a very reliable method," Dr. Pershing said. By contrast, the extracapsular approach has no such limitations and has advanced greatly in the past few years. "I think the advances that have been made over the last decade or so are almost commensurate with phaco," Dr. Pershing said. "I was able to get excellent results, which may be kind of surprising to those of us in the Western system since we automatically tend to assume that phaco is infinitely superior." The approach has changed dras- tically from the old-style, large-inci- sion manual extracapsular procedure of 20 or 30 years ago. Both incision size and configuration have changed. "We used to make a large, 13-mm, smile-shaped incision, going parallel to the limbus superi- orly, underneath the eyelid, starting from around 12 o'clock," Dr. Persh- ing said. "But now experienced sur- geons who have done this technique could make an incision that is more along the lines of 5-8 mm. Even if it's larger, if it's a bit more posterior and shaped in a straight line or is a frown incision, we can get excellent results in terms of astigmatism," Dr. Pershing said. "We can even have a self-sealing wound that can be rein- forced with a suture." Comparable results In reviewing the literature, investiga- tors found that results with the extracapsular technique were sur- prisingly comparable to those with phacoemulsification. Dr. Pershing cited a study that appeared in the January 2007 issue of the American Journal of Ophthalmology that showed remarkably close results for both phacoemulsification and the extracapsular procedure. "The most impressive thing about it was that it looked at a comparison between ex- perts in both techniques," she said. "The phacoemulsification was per- formed by David Chang, M.D., and the manual fix was performed by an expert in that technique and was done in Nepal." Results were compa- rable. At the 6-month mark, 98% of both extracapsular and phacoemul- sification patients had best corrected visual acuity of 20/60 or better. Dr. Pershing sees such results as bringing to light some important differences in dealing with dense cataracts, as might be found in Nepal. "In countries like Nepal where the cataracts are left to advance fairly late, we end up using very high phaco energy," Dr. Pershing said. "This results in a bit more corneal post-operative edema and presumable endothelial cell loss." In keeping with that, in the comparative study investigators no- ticed a bit less corneal edema with the extracapsular technique versus phacoemulsification. "This is be- cause we're expressing the lens," Dr. Pershing said. "There is some trauma deflation of the eye but it doesn't have quite the length as trying to do phaco." There have been a few studies comparing endothelial cell loss with the two techniques. "The difference is pretty negligible but it's a bit less with the manual extracap with the small-incision technique," Dr. Pershing said. In the review article, investiga- tors also considered endophthalmi- tis rates. While both rates were low, there was a threefold difference found. This difference, however, is not as great as some might think. "The cases done were sutureless small-incision extracaps," Dr. Pershing said. "Even if it's self-seal- ing and doesn't leak, with an inci- sion that large it might be safer to put a suture in place." Dr. Pershing pointed out that previous studies have shown that traditional large-in- cision extracap with a suture had a lower endophthalmitis risk than su- tureless phaco. "It would be interest- ing to see what the results would be for a suture small-incision extracap versus phaco. We suspect that it would be pretty comparable," Dr. Pershing said. Dr. Pershing hopes that practi- tioners come away from the study with a better understanding of the place of extracapsular surgery in their armamentarium. "Manual fix shouldn't be abandoned as a historic procedure but should be considered as an alternative to phacoemulsifica- tion and as part of a good surgeon's skill set," Dr. Pershing said. EW Editors' note: Dr. Pershing has no fi- nancial interests related to her com- ments. Contact information Pershing: Suzannpershing@gmail.com March 2011 by Maxine Lipner Senior EyeWorld Contributing Editor The inside scoop on extracapsular cataract surgery Research continued from page 25 Dr. Rajan said that his patients are not bothered by residual but re- duced haze. They might complain of some loss in contrast sensitivity, but it's not a major issue to them. EW Editors' note: Dr. Khakshoor has no fi- nancial interests related to this study. Dr. Rajan has no financial interests re- lated to his comments. Contact information Khakshoor: hkhakshoor@yahoo.com Rajan: rajaneye@vsnl.com In some instances, modern manual extracap can offer results comparable to phacoemulsification Source: Suzann Y. Pershing, M.D.

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