|Year : 2012 | Volume
| Issue : 3 | Page : 157-160
Sutureless large incision cataract extraction: Indications and results from two teaching hospital eye departments in the United Kingdom
Mohammad I Khan1, Shamsuzzoha Syed2, Mala Subash3, Ali Mearza3, Mohammed Muhtaseb1
1 Singleton Hospital, Abertawe Bro Morgannwg University NHS Trust, Swansea, United Kingdom
2 Johns Hopkins University, Bloomberg School of Public Health, Baltimore, USA
3 Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
|Date of Web Publication||15-Jan-2013|
Mohammad I Khan
Department of Ophthalmology, Singleton Hospital, ABM university hospital NHS Trust, Sketty Lane, Swansea, SA2 8QA
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To highlight the role of Sutureless Large Incision Cataract Extraction (SLICE) in the United Kingdom for the treatment of cataracts at high risk for intra- or postoperative complications.
Setting: Two University Hospitals in the United Kingdom
Materials and Methods: Retrospective case note review of planned SLICE performed over a 12-month period.
Results: SLICE was performed on 11 eyes of 11 patients (mean age, 79 years) having preoperative vision of hand motions (10 eyes) with very dense or mobile cataracts and high risk for phacoemulsification. Mean follow up was 12 weeks, with no operative or postoperative complications. Nine patients (without ocular or systemic comorbidity) achieved best corrected vision of 0.3 LogMAR (20/40) or better.
Conclusions: SLICE is safe and effective for dense or mobile cataracts and can play a role in patients where conventional phacoemulsification carries higher risks of complications.
Keywords: Brunescent cataract, cataract, manual small incision cataract surgery, SLICE
|How to cite this article:|
Khan MI, Syed S, Subash M, Mearza A, Muhtaseb M. Sutureless large incision cataract extraction: Indications and results from two teaching hospital eye departments in the United Kingdom. Oman J Ophthalmol 2012;5:157-60
|How to cite this URL:|
Khan MI, Syed S, Subash M, Mearza A, Muhtaseb M. Sutureless large incision cataract extraction: Indications and results from two teaching hospital eye departments in the United Kingdom. Oman J Ophthalmol [serial online] 2012 [cited 2020 Jan 24];5:157-60. Available from: http://www.ojoonline.org/text.asp?2012/5/3/157/106095
| Introduction|| |
Phacoemulsification is the default technique of choice for cataract surgery in the developed world. ,, In developing countries, extra capsular cataract extraction (ECCE) or Sutureless Large Incision Cataract Extraction (SLICE) is being performed with acceptable outcomes.  SLICE was first described in 2000 and since then it has gained popularity in the developing nations as it is quick, cheap, and produces consistently good results. 
In the United Kingdom, including our two units, phacoemulsification is routinely performed for cataract surgery. We felt that in certain high-risk cases, conventional phacoemulsification can lead to visually very significant complications like corneal edema or decompensation, wound burn, posterior capsule tear, vitreous loss, zonular dehiscence, or even dropped nucleus. , Cases were deemed to be high risk if they exhibited any combination of the following features as judged by the operating surgeon (MM or AM): extremely dense cataract, or very dense cataract in the presence of pseudoexfoliation, loose zonules/phacodonesis, Fuchs' endothelial dystrophy, poor patient co-operation/positioning, other confounding factors. Under such circumstances, there is an elevated risk for intra- and postoperative complications as described above.  Such complications may be severely deleterious for the patient's visual prognosis and necessitate further difficult surgery. For example, a patient with a very dense cataract and Fuchs' endothelial dystrophy may have routine phacoemulsification and suffer corneal decompensation necessitating further surgery by way of Descemet's stripping endothelial keratoplasty and all the accompanying implications for medication use and hospital visits. The same patient may have complicated phacoemulsification and suffer posterior capsule rupture with vitreous loss and dropped nucleus fragment or retinal detachment. This would necessitate further vitreoretinal surgery, possibly in the presence of a decompensated cornea. Many such patients also have a significant medical history that requires consideration for length of time they can lie prone or their ability to sustain general anesthesia.
In these specific cases, we opted for SLICE (also known as manual small incision cataract surgery) and have looked at all the cases performed at our two units over a 12-month period.
| Materials and Methods|| |
This was a retrospective case note review of consecutive cases undergoing planned SLICE over a 12-month period; eight cases were performed at Singleton Hospital and three cases at Charing Cross Hospital. Cases were identified from the prospectively collected log by the consultants performing the surgeries (MM and AM). The decision to perform SLICE was made in advance of surgery or on the day of surgery after examining the patient and taking into consideration the slit lamp findings as well as individual patient circumstances. Patient demographics including any ocular or systemic comorbidities, best corrected visual acuity (BCVA) and refraction before and after surgery as well as any complications were studied.
All patients were prepared in the usual manner for surgery and had a sub-tenon or peribulbar anesthetic. The surgical steps of SLICE have been described previously.  Briefly, it involved superior conjunctival peritomy followed by a 6-7 mm half-depth scleral incision 1.5-2 mm behind the limbus and a scleral tunnel extending 1-2 mm into clear cornea and being wider at its internal ostium (9-10 mm) than its external opening. A paracentesis is made inferotemporally and the superior corneoscleral tunnel is opened into the anterior chamber using a 2.6-mm keratome. Tryptan blue is used to stain the capsule and a generous 7-mm continuous curvilinear capsulorhexis is performed. The corneoscleral tunnel is fully opened and generous viscoelastic is used to maintain the anterior chamber during hydrodissection. The nucleus is dialled into the anterior chamber, separated from the posterior capsule and corneal endothelium by further generous viscoelastic, and expressed using an irrigating vectis. After aspirating the soft lens matter, an acrylic intraocular lens is inserted in the bag, viscoelastic aspirated, and the anterior chamber formed with balanced saline solution. The conjunctiva is closed with cautery. Patients were seen at 1 day, 1 week, 4-6 weeks, and 12 weeks postoperatively.
| Results|| |
Eleven eyes of 11 patients had planned SLICE during a 12-month period and five patients were male. The mean age was 79.2 years ± SD 9.4 (range, 59 to 91) and the mean follow-up duration was 12 weeks.
Ten eyes (91%) had preoperative vision of hand motions or worse, while the remaining one eye had BCVA of LogMAR 0.48 (20/60). One eye (9%) had advanced pseudoexfoliation, while three eyes (27%) had age-related macular degeneration (ARMD) that contributed significantly to reduced vision, although the diagnosis of ARMD was made postoperatively in all three cases. One of the patients with ARMD also had significant Fuchs' endothelial dystrophy. There was no fundal view in ten eyes (91%) due to dense cataracts and B-scan ultrasound was used to confirm an attached retina. Schizophrenia, Alzheimer's, cerebral palsy, and significant posturing issues were found in 4 (36%) of our patients and in one patient, we could not get postoperative visual acuity or subjective refraction. Ten patients (91%) were British Caucasians, while the last patient was of a Somalian background.
There were no complications seen during or after surgery. None of the patients showed clinical corneal edema the following day and vision stabilized at around 3 weeks postoperatively, though BCVA and refraction was taken at 5 to 6 weeks postoperatively. The visual and refractive outcomes are shown in [Table 1]. In our series, nine patients (81.8%) achieved BCVA of LogMAR 0.3 (20/40) or better postoperatively; one patient was unable to be tested formally due to learning disabilities and one patient's vision did not change due to advanced atrophic macular degeneration, but navigational vision improved dramatically and he was subjectively happy with the outcome (this was the patient with Fuchs' endothelial dystrophy). Though our numbers are small, we have not encountered any complications in our series and the mean astigmatism, though slighter higher postoperatively, was not statistically significant (P = 0.196).
| Discussion|| |
Since SLICE was first described in 2000 by Ruit et al., it has become a popular technique for cataract extraction in the developing world.  SLICE is the preferred technique over ECCE as it provides better unaided visual acuities while maintaining the low cost and low complication rates.  It is also a significantly faster procedure, making it an ideal technique for surgeons performing high-volume cataract surgeries. 
In the developing world, SLICE has many advantages over ECCE: (1) the lack of sutures means that suture-related complications (such as suture infections and broken sutures) are not a burden for people who often cannot attend the eye clinic again because of the distance that they would need to travel; (2) the lack of sutures also means that the induced astigmatism is less than that occurs with ECCE and so the final unaided visual acuity will be better with SLICE; (3) faster visual recovery and ability to resume normal functions. 
In a developed country like the United Kingdom, phacoemulsification is the routine technique for cataract surgery. On occasions, we do see brunescent cataracts (with or without pseudoexfoliation, Fuchs' endothelial dystrophy, and other confounding factors) in patients who might have other comorbidities making them significantly high risk for the phacoemulsification surgery. Performing prolonged phacoemulsification in such cases can lead to several complications due to stress on zonules and damage to endothelial cells. Dense, mobile, or brunescent cataracts were selected for SLICE in our departments, as it was felt that an acceptable visual outcome can be achieved while preventing or minimizing the complications.
It has been shown in randomized control trials that SLICE can achieve similar visual outcomes to phacoemulsification. , There was similarly no significant difference between the mean astigmatism and the endothelial cell loss at 6 weeks postoperatively between SLICE and phacoemulsification. ,
There are several differences between ECCE and SLICE that mean SLICE is not simply "an ECCE but without the sutures." First, the anterior chamber is flattened in ECCE when the incision is fully opened, whereas SLICE maintains the anterior chamber at all times. Second, there is considerable stress placed on the zonules in ECCE, such as that occurs during expression of the cataract from within the capsular bag by using a vectis beneath the cataract inside the bag and a second instrument (such as a squint hook) on the external aspect to produce "ballotting" of the cataract. This does not occur in SLICE since the nucleus is dialled into the anterior chamber with minimal zonular stress, and it is then expressed from the anterior chamber without any external forces being applied and without stressing the capsular bag or zonules. Third, irrigation and aspiration of the epinuclear material and placement of the intraocular lens are performed with a formed anterior chamber in SLICE, which is not the case in ECCE.
Overall, ECCE has been an extremely valuable operation for the relief of blindness due to cataract all over the world, including the developed world. However, the advantages of SLICE over ECCE and over phacoemulsification for the treatment of high-risk cataract patients in the developed world should prompt surgeons to consider adopting this technique for the few patients in whom phacoemulsification may not be the best treatment option. A recent paper from Nepal suggested that increasing number of patients are presenting earlier in rural areas and have higher visual expectations making them suitable for phacoemulsification.  This paper commented that ophthalmologists should be a "complete cataract surgeon" and must be able to perform ECCE, SLICE, and phacoemulsification, so that they can choose the best technique depending on the patient's circumstances. We think this also applies to the developed world surgeons and on those few occasions when we come across significantly dense cataracts with high risks of perioperative complications, SLICE should be considered as an alternative if that seems to be the safer option.
The limitations of our study include the retrospective study design, small sample size, and short follow-up duration. However, we want to demonstrate that SLICE can be a safe and effective technique for eyes that are considered to have a higher risk of intraoperative complications when operated by conventional phacoemulsification. It is important to emphasize here that we are not describing a new technique but only suggesting to consider its use in the developed world for patients who may be at significantly high risk for conventional phacoemulsification surgery.
There is a small but steadily growing literature on the potential benefits developed countries can gain from experiences in developing countries. The importance of this type of learning has been recently highlighted both in global health and global business. , Furthermore, a range of clinical benefits derived from the developing world (both at system and individual practitioner levels) are percolating the literature. ,,,, In fact, some global partnership focused programs place a clear emphasis on bi-directional knowledge transfer between front line healthcare professionals in the developed and developing world.  The potential use of SLICE in a sub-group of ophthalmology patients in the United Kingdom described in this paper adds to the global pool of knowledge on such bidirectional knowledge transfer.
| Conclusion|| |
SLICE is a safe and effective technique and is a useful alternative in high-risk cases like dense, brunescent, or mobile cataracts. It should be considered even in a developed world setting where phacoemulsification is usually the technique of choice.
| References|| |
|1.||Desai P, Minassian DC, Reidy A. National cataract surgery survey 1997-8: A report of the results of the clinical outcomes. Br J Ophthalmol 1999;83:1336-40. |
|2.||Lundstrom M, Barry P, Leite E, Seward H, Stenevi U. 1998 European Cataract Outcome Study: Report from the European Cataract Outcome Study Group. J Cataract Refract Surg 2001;27:1176-84. |
|3.||Ang GS, Wheelan S, Green FD. Manual small incision cataract surgery in a United Kingdom university teaching hospital setting. Int Ophthalmol 2010;30:23-9. |
|4.||Ruit S, Tabin G, Chang D, Bajracharya L, Kline DC, Richheimer W, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol 2007;143:32-8. |
|5.||Ruit S, Paudyal G, Gurung R, Tabin G, Moran D, Brian G. An innovation in developing world cataract surgery: Sutureless extracapsular cataract extraction with intraocular lens implantation. Clin Exp Ophthalmol 2000;28:274-9. |
|6.||Venkatesh R, Tan CS, Singh GP, Veena K, Krishnan KT, Ravindran RD. Safety and efficacy of manual small incision cataract surgery for brunescent and black cataracts. Eye 2009;23:1155-7. |
|7.||Muhtaseb M, Kalhoro A, Ionides A. A system for preoperative stratification of cataract patients according to risk of intraoperative complications: A prospective analysis of 1441 cases. Br J Ophthalmol 2004;88:1242-6. |
|8.||Venkatesh R, Muralikrishnan R, Balent LC, Prakash SK, Prajna NV. Outcomes of high volume cataract surgeries in a developing country. Br J Ophthalmol 2005;89:1079-83. |
|9.||Gogate PM, Deshpande M, Wormald RP, Deshpande R, Kulkarni SR. Extracapsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: A randomised controlled trial. Br J Ophthalmol 2003;87:667-72. |
|10.||Gogate PM, Kulkarni SR, Krishnaiah S Deshpande RD, Joshi SA, Palimkar A, et al. Safety and efficacy of phacoemulsification compared with manual small-incision cataract surgery by a randomized controlled clinical trial: Six-week results. Ophthalmology 2005;112:869-74. |
|11.||George R, Rupauliha P, Sripriya AV, Rajesh PS, Vahan PV, Praveen S. Comparison of endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small-incision surgery and phacoemulsification. Ophthalmic Epidemiol 2005;12:293-9. |
|12.||Hennig A, Singh S, Winter I, Yorston D. Can Phaco be a cost effective solution to cataract blindness? Costs and outcomes in Nepal. Eye 2010;24:1104. |
|13.||Crisp N. Learning from low- and middle-income countries. In Turning the World Upside Down: The search for global health in the 21st Century, Chapter 6: The Royal Society of Medicine Press Limited; London. 2010. p. 105-26. |
|14.||Immelt JR, Govindarajan V, Trimble C. How GE is disrupting itself. USA: Harvard Business Review; 2009. p. 56-65. |
|15.||Berwick DM. Lessons from developing nations on improving health care. BMJ 2004;328:1124-9. |
|16.||McKenzie K, Patel V, Araya R. Learning from low income countries: Mental health. BMJ 2004;329:1138-40. |
|17.||Richards T, Tumwine J. Poor countries make the best teachers: discuss. BMJ 2004;329:1113-4. |
|18.||Ruiz-Pelaez JG, Charpak N, Cuervo LG. Kangaroo Mother Care, an example to follow from developing countries. BMJ 2004;329:1179-81. |
|19.||Bowman R. I went; I saw: I was never the same! Br J Ophthalmol 2002;86:370-1. |
|20.||Syed SB, Gooden R, Storr J, Hightower JD, Rutter P, Bagheri Nejad S, et al. African Partnerships for Patient Safety: A vehicle for enhancing patient safety across two continents. World Hosp Health Serv 2009;45:24-7. |