|Year : 2015 | Volume
| Issue : 2 | Page : 96-100
Outcome of surgery in a manual small incision cataract surgery training in Calabar, Nigeria
DG Nkanga, UE Asana, BA Etim, AA Ibanga, ED Nkanga
Department of Ophthalmology, University of Calabar Teaching Hospital, University of Calabar, Calabar, Cross River, Nigeria
|Date of Web Publication||16-Jun-2015|
Dr. D G Nkanga
Department of Ophthalmology, University of Calabar Teaching Hospital, University of Calabar, PMB 1115, Calabar, Cross River State
Source of Support: None, Conflict of Interest: None
Background: Cataract is the leading cause of blindness in developing countries. Phacoemulsification is beyond the reach of many in these resources limited setting. Manual Small Incision Cataract Surgery (SICS) is a safe, low-cost, high-quality alternative. This is a review of outcome of SICS performed by trainee Surgeons during the first SICS training course in our centre.
Patients and Methods: Eleven experienced Extracapsular Cataract Extraction (ECCE) surgeons from training centers across Nigeria were selected for a weeklong SICS training and conversion course. A review of visual outcome and complications of surgeries performed by these trainees on adult subjects is here reported.
Results: Eighty-two eyes met the inclusion criteria. Male to female ratio was 1.4:1. Intraocular lenses were implanted in 80 eyes (97.5%). Visual outcome at 3 months post-operatively was good in 58 eyes (70.7%), borderline in 20 (24.4%), and poor in 4 (4.9%) subjects. The most common late post-operative complication, resulting in poor outcome was uncorrected aphakia in 2 (2.4%) eyes.
Conclusion: The outcome did not meet World Health Organization (WHO) recommendations but was better than that reported for ECCE in the country. Conversion to SICS may not be difficult for competent ECCE surgeons as trainees achieved reasonable dexterity with acceptable post-operative outcome and complications profile in one week. To maximize patient safety and good outcome, a longer training period is recommended.
Keywords: Cataract surgery, cataract, intraocular lenses, manual small incision
|How to cite this article:|
Nkanga D G, Asana U E, Etim B A, Ibanga A A, Nkanga E D. Outcome of surgery in a manual small incision cataract surgery training in Calabar, Nigeria. Arch Int Surg 2015;5:96-100
|How to cite this URL:|
Nkanga D G, Asana U E, Etim B A, Ibanga A A, Nkanga E D. Outcome of surgery in a manual small incision cataract surgery training in Calabar, Nigeria. Arch Int Surg [serial online] 2015 [cited 2020 Oct 24];5:96-100. Available from: https://www.archintsurg.org/text.asp?2015/5/2/96/158824
| Introduction|| |
Cataract is the world's leading cause of curable blindness.  Cataract blindness is increasing by approximately 1 million annually and the number of 'operable' cataracts with visual acuity of less than 6/60 is increasing by 4-5 million per year.  To achieve the goal of eliminating avoidable blindness by 2020, global efforts need to be directed not only towards increasing coverage and output but also towards improving the quality of cataract surgical services.  This is why cataract surgery is constantly evolving and novel microsurgical techniques are being adopted.
Phacoemulsification has made tremendous impact on ophthalmology in the last three decades with over 85% of all cataract surgeries in the United States and the United Kingdom performed using this technique.  This however requires a sophisticated setup at cost consideration sometimes beyond the reach of developing world patients, many of which live on less than two dollars a day, have no insurance cover, and have to make out of pocket payments to obtain treatment. , This along with limited training opportunities and high proportion of mature cataracts with rock hard nuclei have contributed in limiting the role of phacoemulsification in Sub-sahara Africa  where Extracapsular Cataract Extraction (ECCE) is still the most common intervention for cataract. 
Cost of surgery is an important barrier to uptake of cataract surgical services in Africa. ,, There is need for the adoption of a safe, low cost, high quality, versatile surgical technique with good patient acceptability. The Manual Small Incision Cataract Surgery (SICS) fits this description as it offers many of the advantages of phacoemulsification at lower cost. , It offers better patients comfort, minimal surgically induced astigmatism, faster post-operative rehabilitation without suture related complications and can be practiced even in the most remote places with affordable technology. ,, It has also been suggested that the SICS technique is easier to learn for ophthalmic surgeons experienced in standard ECCE technique when compared with phacoemulsification. 
In September, 2005 a weeklong hands on 'train the trainers' conversion course was held at the University of Calabar Teaching Hospital (UCTH) Calabar, Nigeria, to convert experienced ECCE surgeons to the SICS technique. This is a review of the visual outcome and complications of SICS performed by the trainees during that course.
| Patients and Methods|| |
Eleven experienced ECCE surgeons, all active trainers drawn from training centers across Nigeria were admitted into a SICS training course as trainees. Patients were recruited and included for the course after a written informed consent was obtained. A review of outcome of SICS performed completely by trainees on adult patients with cataracts during the course from September 19 th to 23 rd 2005 in the University of Calabar Teaching Hospital, Calabar are included in this study. Ethical approval was obtained from the ethical committee of University of Calabar Teaching Hospital. Excluded from the study were those patients who were thought to have guarded prognosis pre-operatively, patients with other co-existing ocular pathologies, patients with traumatic or uveitic cataracts, patients whose surgeries were not completed by trainees, and patients who did not show up for the complete follow-up period of 3 months.
All patients had biometry performed using Grand Seiko autokeratometer GR 3100K for keratometry and Sonomed Pacscan300A for A scan and IOP power calculation. IOLS used depended on availability of the right power. Where that was not the case, IOL powers closest to that determined by biometry was used.
Visual outcome was classified based on the WHO standards for outcome measurements as good for Visual acuity (VA) 6/18 and better, borderline for VA less than 6/18-6/60 and poor for VA less than 6/60.
The Goutami Eye Institute training CD ROM was used as the basic training tool. Trainers first demonstrated surgical technique, took trainees through close supervision of every step of the procedure till reasonable dexterity was achieved. Trainees were then allowed to perform surgery under supervision. The surgical technique consisted of the following steps:
- Peribulbar and facial nerve block with 2% Xylocaine with adrenaline after skin preparation with 10% povidone iodine.
- Fornix-based conjunctival incision was placed using a temporal approach after irrigation with 5% povidone iodine.
- A linear partial thickness sclera incision 2mm behind the limbus and 6.5 mm wide was made using a size 15 surgical blade.
- The sclera-corneal tunnel was created using an angled 2.3 mm cre scent knife bevel up. The internal opening was wider, at least 8.5 mm.
- A paracentesis was performed with an angled sideport knife dual bevel 1.0 mm, followed by opening into the anterior chamber through the sclera-corneal tunnel using a 3.2 mm angled dual bevel keratome.
- The anterior chamber was filled with viscoelastic (Hydroxypropyl methylcellulose) and a can-opener capsulotomy or continous curvilinear capsulorhexis was performed.
- After hydrodissection, or hydrodeliniation, the nucleus was mobilized into the anterior chamber.
- Viscoelastic was introduced above and below the lens nucleus which was then delivered with the aid of either visco expression or lens loop. Residual cortex was cleared using the Simcoe cannula, the anterior chamber was refilled with viscoelastic and a posterior chamber IOL implanted before the viscoelastic was finally aspirated and anterior chamber reformed.
Care was taken to ensure the wound was self-sealing, paracentesis was hydrated, before Gentamycin and dexamethasone were injected subconjunctivally and instilled as eye drops. Patients were discharged a day after surgery. Patients with significant post operative concerns were kept for medical management as indicated. All patients were reviewed one week, one month and three months after surgery in the outpatient clinic. Presenting visual acuities and complications at each visit were recorded.
| Results|| |
Eighty two eyes of the 170 eyes operated during the exercise met the inclusion criteria. Ages of patients ranged between 19-80 with a peak at 60-69 as shown in [Table 1]. Mean age 58.35 ± 14.2 years. Forty-eight patients (58.5%) were males and thirty-four (41.5%) were females with a male to female ratio of 1.4:1.
Preoperatively, 76 (92.7%) eyes were blind with 2 (2.4%) eyes severely visually impaired and 4 (4.9%) being visually impaired as shown in [Figure 1].
IOLs were implanted in 80 eyes (97.5%). Seventy seven were PC IOLs and three were AC IOLs, while 2 (2.4%) eyes were left without primary IOLs due to intra-operative complications.
Applying the WHO visual outcome classification for uncorrected vision at 3 months post-operatively 58 eyes (70.7%) had good outcome, 20 (24.4%) had borderline, while 4 (4.9%) had poor outcome as shown in [Table 2].
|Table 2: Visual outcome three months post-operatively and causes of poor outcome |
Click here to view
Intra operative and immediate post-operative Complications occurred in 24 (29.3%) eyes as shown in [Figure 2]. The most common was post-operative corneal edema. Two patients had significant corneal edema requiring admission for several days one of which later had bullous keratopathy as a cause of poor outcome at 3 months. Vitreous loss following posterior capsule rent occurred in 9 (11%) eyes. Two patients had intra and post-operative hyphaema which cleared within 3 days. The most common post-operative complication at 3 months, resulting in poor outcome was uncorrected aphakia in 2 (2.4%) eyes as shown in [Table 2].
| Discussion|| |
Cataract surgical techniques are undergoing changes both in the developed and developing world.  Phacoemulsification is still the standard of care for cataract treatment in the western world. ,, However, in developing countries phacoemulsification can only be afforded by the affluent.  Depending on phacoemulsification technique alone for the treatment of operable cataracts in developing countries would likely contribute to increasing cataract backlog and the burden of avoidable blindness.
Phacoemulsification may also not be the ideal technique for the frequently encountered 'rock hard' cataracts (Catarocks) of 'resource limited' settings. It therefore may continue to play a limited role in the reduction of cataract blindness in such settings in the foreseeable future.  The steep learning curve for converting surgeons from standard ECCE technique to phacoemulsification, besides cost, also constitute a hindrance. Conversion to a less expensive SICS with all its advantages may serve as a logical first step.
SICS like phacoemulsification is associated with rapid visual recovery, greater wound stability with no suture related complications. ,, This has prompted eye surgeons in developing countries to evolve and promote SICS; a technique adapted to low-technology environment but with results comparable to phacoemulsification. ,, This necessitated our training course.
Seventy-six (92.7%) eyes were categorized as blind pre-operatively and 6 (7%) eyes with visual impairment which is similar to another study in Abak, Nigeria.  At 3 months post-operatively 4 eyes (4.9%) remained blind. Worthy of note is the significant number of patients who were blind prior to surgical intervention as this is known to affect outcome directly.  The number of blind pre-operatively was lower in the Sierra Leone study where only 51% of patients were blind in the better eye prior to surgery.  Our population was comparable with the Ghanaian study, where the pre-operative visual acuity was count finger or worse in all but one patient.  Another study in East Africa showed 84.6% of eyes were blind preoperatively.  It has been documented that poorer pre-operative visual acuities are associated with poorer outcome and this should be taken into consideration when evaluating visual outcome of cataract surgeries from developing countries. 
The 3 month uncorrected, post-operative visual outcome where 58 eyes (70.7%) had good outcome, 20 (24.4%) had borderline, while 4 (4.9%) had poor outcome did not meet the WHO standards of good outcome of >80% and <5% with poor outcome.  The fact that not every patient could get the appropriate IOL as determined by biometry probable played some role. However, the visual outcome even with all the limitations was better than reports of outcome of ECCE with PCIOL in developing countries ,,, probably underlining the superiority of the SICS technique and the relative ease of conversion to the technique.  Henning et al., however reported higher rates of uncorrected visual acuity >6/18 with manual SICS and theirs was not in a training situation. 
The training course in Lahan showed that ECCE surgeons needed a median of 58 operations whereas Phaco surgeons needed a median of 30 surgeries to attain reasonable levels of proficiency in SICS.  The suggestion that trainees should have performed 100 consecutive ECCE+PCIOL with surgical complications especially PC rent <5% and number of patients with a post-operative uncorrected VA <6/60 below 5% as pre-requisite for admitting surgeons for SICS training course may contribute to improve outcome during training.  The fact that all our trainees were active trainers may have played a role in the relatively good outcome of surgeries.
Complications were seen in 29.3% of eyes with vitreous loss in 11% of subjects. This is far above WHO recommended figures of <10% complications with vitreous loss not exceeding 5%. This was high compared with other manual SICS studies. , This may be related to the fact that this was a training and conversion program.
It should also be stated that this was the first time pre-operative biometry was being performed in this centre and the learning experience could have contributed to the larger number (20 or 24.4%) of patients with borderline visual outcome.
| Conclusion|| |
Conversion to Manual SICS may not be difficult for competent ECCE surgeons as our study shows that reasonable surgical dexterity with acceptable post-operative outcome was achieved in 1 week of intensive hands on surgical training. To maximize good visual outcome, every patient should have biometry pre-operatively and implantation of appropriate IOL has to be the minimum standard of care. Since the SICS technique offers better patient comfort, faster visual recovery and healing of smaller wounds with less astigmatism, without suture related cost and complications, it is recommended as the option of choice in resource limited settings.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]