Abstract
Purpose:
To determine the incidence of vitreous loss and visual outcome after a vitreous loss during cataract surgery performed by surgeons with various levels of experience in adults >40 years of age at a tertiary eye care center in North India.
Methods:
The study was conducted at a tertiary eye care center in North India. This was an observational, retrospective, cross-sectional study of patients who underwent cataract surgery from August 1, 2011 to July 31, 2014. All adult cataract cases who were operated on from August 1, 2011 to July 31, 2014 and who experienced vitreous loss during their surgery were included in the study. The visual outcomes of these patients who experienced vitreous loss during cataract surgery in uncomplicated cataract and were managed using standard automated vitrectomy techniques were assessed for different cataract surgical techniques (extracapsular, small-incision, and phacoemulsification) as well as at different levels of skill of the operative surgeon (consultant, short term fellow, and long-term fellow). Details of the postoperative period and best-corrected visual acuity (BCVA) were collected from patient records by the principal investigator on day 1, 1 week, 4 weeks, 6 weeks, and 3 months post cataract surgery.
Results:
Vitreous loss occurred in 374 out of 18,430 patients who underwent cataract surgery from August 1, 2011 to July 31, 2014. The overall incidence of vitreous loss in our study was found to be 2.03% with consultants having a rate of 1.66%, short-term fellows at 5.19%, and long-term fellows at 2.02%. Two hundred eighty-eight patients of the 374 cases followed up for 3 months at the hospital and 75.69% of these patients had a final visual acuity of ≥6/18.
Conclusion:
In an institute with a structured training program for residents/trainees, the vitreous loss rate is low during cataract surgery. Early intervention and proper management with the standard microsurgical technique by experienced hands can improve the final visual outcome in eyes with vitreous loss. Cystoid macular edema and corneal edema were the most common causes of poor postoperative vision.
Keywords: Cataract surgery, posterior capsular rent, vitreous loss
Vitreous loss remains one of the dreaded complications of cataract surgery despite the use of advanced techniques in the surgery. Vitreous loss has further been found to increase the risk of cystoid macular edema (CME),[1] retinal detachment, and endophthalmitis.[2] This complication of vitreous loss during cataract surgery usually follows the cataract learning curve and is seen more in the initial learning phase or the training period.[3,4] Several studies have shown the incidence of vitreous loss ranging from 0% to 19% in cataract surgeries.[5,6,7] An earlier acceptable figure of less than 3% was proposed by Jaffe.[8] The National Program for Control of Blindness (NPCB) survey has also shown that vitreous loss was the commonest complication of cataract surgery, amounting to 6% of cases.[9]
Different studies have shown different incidences of vitreous loss and visual outcomes during the learning curve from intracapsular cataract extraction (ICCE) to standard extracapsular cataract extraction (ECCE) and small-incision cataract surgery (SICS) to phacoemulsification.[10,11] Smith and Seiff[12] reported a vitreous loss in residency training at various levels of experience. It occurred in 16% of eyes operated by first-year residents, in 10% of eyes operated by second-year residents, and in 6% of eyes operated by third-year residents learning phacoemulsification. Preston and Rajiv[13] reported that good visual acuity can be achieved after resident cataract surgery complicated by vitreous loss. Review of literature did not reveal any definitive conclusion about the poor visual outcome and vitreous loss during cataract surgery.[14,15,16] Our study tried to fill up these lacunae and tried to bring out the factors that affect the final visual outcomes in cataract surgery with vitreous loss.
Our hospital is a tertiary care hospital in North India with both short-term and long-term fellowship programs for cataracts and other ophthalmic sub-specialties. A candidate is given ample surgical hands-on exposure with one-on-one interaction with the patient, but all steps are always closely monitored to maintain a high standard quality. The purpose of our study was to determine the vitreous loss rate and final visual outcome of various types of cataract surgeries complicated by vitreous loss and managed by standard microsurgical techniques at our hospital. We also described the visual outcome after 3 months of posterior capsule rupture and compared the outcome between consultant (faculty) and short-term and long-term fellows.
Methods
Study population
The study population included all patients who underwent cataract surgery at our institute in the period of August 1, 2011 to July 31, 2014 (three years) and experienced vitreous loss during cataract surgery. The visual outcome of patients who experienced vitreous loss and were managed using standard vitrectomy techniques was assessed for different cataract surgical techniques (extracapsular, small-incision, and phacoemulsification) as well as different levels of surgical training (consultant, short-term fellow, and long-term fellow). Details of the postoperative period and best-corrected visual acuity (BCVA) were collected from patient records from the medical record department by the principal investigator on day 1, 1 week, 4 weeks, 6 weeks, and 3 months post the cataract surgery.
Specific objectives were to determine the incidence of vitreous loss during cataract surgery and to assess the visual outcome after a vitreous loss during cataract surgery done in uncomplicated cataracts at 3 months by surgeons of various levels of experience.
Study Design was a retrospective, observational, cross-sectional study among patients who underwent cataract surgery from August 1, 2011 to July 31, 2014.
Inclusion criteria
The study included all adult patients of age more than 40 years who experienced vitreous loss during cataract surgery performed by surgeons of various levels of experience including consultants, short-term fellows, and long-term fellows. All routine cataract surgeries for age-related or uncomplicated, drug-induced cataract was included in the study.
Exclusion criteria
Cases not included in the study were patients undergoing combined surgery, cataract surgery in post–penetrating keratoplasty patients, post–vitreoretinal surgery eyes, and traumatic or complicated cataracts. Patients with preoperative ocular morbidity that could account for poor visual outcome postoperatively, history of any previous ocular surgery in the same eye, amblyopia, or inadequate follow-up were excluded from the study as well. These patients who had vitreous loss were counted for calculating the vitreous loss rate but excluded for calculating the visual outcome.
Our hospital runs a time-bound and structured short-term and long-term intraocular lens (IOL) fellowship training program. In the short-term fellowship program, a candidate is trained in ECCE, SICS, and phacoemulsification for a 1-month duration. For enrolling for SICS, a short-term training candidate should have experience of 20 ECCE and for a phacoemulsification fellowship, the candidate should have experience of a minimum of 150 SICS.
A long-term fellowship in cataract and microsurgery is of a minimum of 15 months duration. During this period, the candidate does a minimum of 20 ECCE, graduating then to SICS. After the candidate is proficient in SICS and is comfortable making a good rhexis, the candidate is trained in phacoemulsification. All fellows are expected to attend the wet lab at the start of the fellowship program. Their skills are assessed by the Ophthalmology Surgical Competency Assessment Rubric (OSCAR) grading and only when they are deemed fit to operate on human eyes by the wet lab in charge (score of 4 out of 5 in every step) are they allowed to do so. All initial cases by fellows were supervised by consultants on a one-on-one basis and depending on the skills of the fellow, they were allowed to do independent surgeries thereafter. Vitreous loss or any other complications happening during the surgery were, however, managed by consultants only.
Surgical methods
Peribulbar anesthesia using 2% lignocaine and 0.5% bupivacaine mixed with hyaluronidase was used by all fellows and a few consultants to block the eye. The rest of the phacoemulsification cases done by consultants were performed under topical anesthesia using 0.5% proparacaine eyedrops and 1% intracameral lignocaine hydrochloride. The technique used for standard ECCE was explained by Jaffee with can-opener capsulotomy and nucleus delivery by pressure counter-pressure and suturing using 10-0 nylon.[8]
SICS was done using either the viscoexpression technique for nucleus delivery or by the use of the Anterior chamber (AC) maintainer. Phacoemulsification was performed either by the Gimbel[17] technique of divide and conquer, that is, dividing the nucleus into four quadrants and then emulsifying each quadrant individually, or by Koch’s stop-and-chop technique.[18] As per the hospital’s protocols, all fellows were initially taught the divide-and-conquer technique, and when they were proficient enough in chopping the nucleus, they were allowed to progress to the stop-and-chop technique.
Vitreous loss was defined as prolapse or anterior displacement of vitreous gel into the anterior chamber beyond the plane of the posterior capsule. It was diagnosed either clinically or with the use of an injection of triamcinolone. All cases of vitreous loss were managed by consultants using an automated anterior vitrectomy machine. Once the vitreous loss was identified, all instruments were removed from the anterior chamber slowly while injecting Ocular viscoelastic device (OVD) from the side port incision. The height of the infusion bottle was lowered immediately. Close chamber automated anterior vitrectomy was performed using an automated anterior vitrectomy machine. Patients who had a nucleus or nucleus fragment drop in the posterior cavity were managed by the retina consultant. The lens was inserted after complete anterior vitrectomy either in the bag, sulcus, or anterior chamber. Anterior chamber intra ocular lene (ACIOL) was not put in patients with decompensated corneas or shallow anterior chambers; some of these patients were later planned for a secondary scleral-supported or an anterior chamber IOL.
Routine follow-up of patients was planned on postoperative day 1, 1 week, 4 weeks, 6 weeks, and 3 months after surgery depending upon the type of surgery performed. Cases with postoperative complications were called more frequently. All patients received topical steroids and antibiotics postoperatively. Depending on the diabetes status of the patient, oral steroids were added based on the intraocular inflammation. On all visits, BCVA was taken, and patients were examined by slit lamp and applanation tonometry. The fundus was examined by using a 90 D lens on a slit lamp, and indirect ophthalmoscopy was performed whenever indicated.
For the final analysis of the visual outcome, the surgeons were divided into three broad categories of consultant, short-term fellow, and long-term fellow, and the visual acuity was divided into four categories based on the World Health Organization (WHO) definition of the cataract outcome.
Category 1: (Good vision) BCVA 6/6 to 6/18
Category 2: BCVA < 6/18 to 6/60
Category 3: BCVA < 6/60 to 3/60
Category 4: (blindness) BCVA < 3/60
These categories are mutually exclusive. All patients with preexisting pathology that account for poor visual acuity were excluded from visual outcome analysis.
Descriptive statistics were analyzed with Statistical Package for the Social Sciences (SPSS) version 17 software. Continuous variables are presented as mean ± SD. Categorical variables are expressed as frequencies and percentages. Correlation between postoperative vision at different time points and designation of surgeons was done using the Chi-squared test. A P value of less than 0.05 was taken as a significant difference.
Results
A total of 18,430 patients of age 40 years and above underwent cataract surgery in the hospital from August 1, 2011 to July 31, 2014. Of these, 8812 were done by consultants, 8577 were done by long-term fellows, and 1041 were done by short-term fellows. There were 417 cases with vitreous loss. Data from 374 patient files that fulfilled the inclusion and exclusion criteria were collected, assessed, and included in the study. Since the surgeries and the complications were divided into multiple surgeons, the difference in the distribution of patients according to the skill of different surgeons individually could not be assessed.
The overall incidence of vitreous loss at our hospital was found to be 2.03%. Consultants had an incidence of 1.66% while that of short-term and long-term fellows was found to be 5.19% and 2.02%, respectively [Table 1].
Table 1.
Incidence of vitreous loss during cataract surgery by different surgeons
| Designation of Surgeon | Number of Cataract Patients | Incidence of Vitreous Loss | % | Consultant vs Long-term Fellow (P) | Consultant vs Short-term Fellow (P) | Long-term Fellow vs Short-term Fellow (P) |
|---|---|---|---|---|---|---|
| Consultant | 8812 | 147 | 1.66% | 0.098 | <0.0001 | <0.0001 |
| Long-term fellow | 8577 | 173 | 2.02% | |||
| Short-term fellow | 1041 | 54 | 5.19% | |||
| Total | 18430 | 374 | 2.03% |
The age range was from 40 years to 85 years as per the inclusion criteria, with a mean age of 63.99 ± 9.25 years. The maximum number of patients with vitreous loss fell in the category of 61–70 years [Table 2]. This was anticipated as the major portion of the population with age-related cataracts falls in this category.
Table 2.
Age distribution
| Age (years) | Frequency | Percentage |
|---|---|---|
| 1) ≤50 | 38 | 10.16% |
| 2) 51-60 | 99 | 26.47% |
| 3) 61-70 | 166 | 44.39% |
| 4) 71-80 | 55 | 14.71% |
| 5) 81-90 | 16 | 4.28% |
| Total | 374 | 100.00% |
No statistically significant difference in vitreous loss between the right eye and left eye of the patients was seen in the study.
In our study, 49.73% of patients were female and 50.27% were male [Table 3]. There was no gender predilection for vitreous loss seen in our study. The distribution of patients according to surgical technique and type of surgeon was shown in Tables 4 and 5. As stated before, we could not find the vitreous loss rate individually for each surgeon owing to the multiplicities of the data involved.
Table 3.
Gender distribution
| Gender | Frequency | Percentage |
|---|---|---|
| Female | 186 | 49.73% |
| Male | 188 | 50.27% |
| Total | 374 | 100.00% |
Table 4.
Number of surgeries that had vitreous loss
| Surgery | Frequency | Percentage |
|---|---|---|
| Extracapsular cataract extraction (ECCE) | 85 | 22.73% |
| Intracapsular cataract extraction (ICCE) | 9 | 2.41% |
| Phacoemulsification | 150 | 40.11% |
| Small-incision cataract surgery (SICS) | 130 | 34.76% |
| Total | 374 | 100.00% |
Table 5.
Vitreous loss related to designation of surgeon
| Designation | Frequency | Percentage |
|---|---|---|
| Consultant | 147 | 39.30% |
| Long-term fellow | 173 | 46.26% |
| Short-term fellow | 54 | 14.44% |
| Total | 374 | 100.00% |
Of the total 374 patients who developed vitreous loss, 40.11% occurred in phacoemulsification, 34.76% in SICS, and 22.73% in ECCE. ICCE was performed in 9 patients, of which 8 had a subluxated nucleus preoperatively, while 1 case was converted from ECCE to ICCE during the surgery because of intraoperative complication. The higher rate of vitreous loss in phacoemulsification is due to more number of surgeries being performed in this category [Table 4].
The most common cause of vitreous loss found in our study was a posterior capsule rupture unaccompanied by any other complication with a rate of 76.74%. This was followed by vitreous loss secondary to zonular dialysis. Eleven cases were seen to have a nucleus or a nucleus/epinucleus fragment drop which were managed by the retina specialists either on the same day or as a secondary surgery.
The various causes of vitreous loss during surgery are shown in Table 6.
Table 6.
Distribution of complications
| Complication | Frequency(%) |
|---|---|
| Posterior capsular rupture (PCR) | 287 (76.74%) |
| Zonular dialysis (ZD) | 51 (13.63%) |
| PCR + ZD | 3 (0.8%) |
| PCR + Iridodialysis | 3 (0.8%) |
| PCR + DMD | 3 (0.8%) |
| ZD + Iridodialysis | 1 (0.26%) |
| ZD + PCR + Iridodialysis | 1 (0.26%) |
| PCR + Nucleus/Epinucleus/Fragment Drop | 11 (2.94%) |
| Expulsive choroidal hemorrhage | 2 (0.53%) |
| ICCE | 9 (2.4%) |
| Cause not mentioned in file | 3 (0.8%) |
| Total | 374 (100%) |
Out of these 374 patients, an ACIOL was put in 144 patients (38.5%) because of the simplicity of the procedure over scleral-fixated IOLs and the less cost involved. Posterior chamber intra ocular lens (PCIOL) in the bag was put in 11 patients (2.94%) who had good posterior capsule support with a small rent and PCIOL in the sulcus was put in 156 patients (41.71%) with poor posterior capsule support but a good anterior capsule. Sixty-three patients (16.84%) were left aphakic because of a lack of capsule support, a very shallow AC depth, or poor quality of endothelium. These cases were later followed up for a secondary IOL implantation [Table 7]. Of these, 14 patients (22.22%) had a secondary IOL while 2 patients refused to undergo a second surgery. Six patients were lost to follow-up though they were advised a secondary IOL. In 41 patients (65.08%), it was decided not to put a secondary IOL as the vision was not improving with refraction.
Table 7.
IOL status post surgery
| Frequency | Percentage | |
|---|---|---|
| ACIOL | 144 | 38.50% |
| PCIOL in bag | 11 | 2.94% |
| PCIOL in sulcus | 156 | 41.71% |
| Aphakia | 63 | 16.84% |
| Total | 374 | 100.00% |
Vitreous loss in surgeries done by long-term fellows (173) far exceeds those seen in consultants (147) and those in short-term fellows (54) as shown in Table 5.
A considerable number of patients were found to have associated comorbidities [Table 8] in the study, but these did not seem to affect the rate of vitreous loss though the treatment given, especially oral steroids, was modified according to the patient’s diabetic status. A clearance from the hospital physician was taken before starting treatment in these patients.
Table 8.
Comorbidities
| Comorbidities | Frequency | % |
|---|---|---|
| None | 232 | 62.03% |
| Cardiac illness | 7 | 1.87% |
| Diabetes | 63 | 16.84% |
| Hypertension | 97 | 25.94% |
| Asthma | 3 | 0.8% |
| Others | 16 | 4.28% |
The category-wise visual outcome was finally calculated for consultants, long-term, and short-term fellows after 3 months of surgery. The vision on the first postoperative day was found to be less than 3/60 (category 4) in 55.61% of patients, but by the end of 3 months this was seen in only 4.01% of patients [Table 9]. At the end of 3 months, 288 out of 374 came for follow-up: 75.69% of these patients (218/288) had a BCVA of more than 6/18, and 24.3% (70/288) had visual outcomes less than 6/18. Causes of a visual outcome of less than 6/18 in 70 patients are shown in Table 10.
Table 9.
Category-wise final visual outcome
| Category 1 | Category 2 | Category 3 | Category 4 | Loss to Follow up | Total | |
|---|---|---|---|---|---|---|
| Pre-op vision | 38 | 115 | 23 | 198 | 0 | 374 |
| 10.16% | 30.75% | 6.15% | 52.94% | 0.0% | 100% | |
| POD-1 | 39 | 113 | 13 | 208 | 1 | 374 |
| 10.43% | 30.21% | 3.48% | 55.61% | 0.27% | 100% | |
| POD-7 | 76 | 127 | 27 | 131 | 13 | 374 |
| 20.32% | 33.96% | 7.22% | 35.03% | 3.48% | 100% | |
| POD-4 week | 131 | 130 | 24 | 52 | 37 | 374 |
| 35.03% | 34.76% | 6.42% | 13.90% | 9.89% | 100% | |
| POD-6 week | 182 | 89 | 12 | 26 | 65 | 374 |
| 48.66% | 23.8% | 3.21% | 6.95% | 17.38% | 100% | |
| Final follow-up (3 months) | 218 | 46 | 9 | 15 | 86 | 374 |
| 58.29% | 12.3% | 2.41% | 4.01% | 22.99% | 100% |
Table 10.
Cause of vision <6/18
| Frequency | Percentage | |
|---|---|---|
| CME | 15 | 21.43% |
| Corneal decompensation/Corneal edema | 10 | 14.28% |
| Macular degeneration | 10 | 14.28% |
| Diabetic retinopathy | 5 | 7.14% |
| Optic atrophy/Pale disc | 5 | 7.14% |
| Corneal opacity | 4 | 5.71% |
| ERM | 1 | 1.42% |
| Vitritis+CME | 1 | 1.42% |
| Coloboma+Myopic disc | 1 | 1.42% |
| Macular scar | 2 | 2.86% |
| Secondary glaucoma | 2 | 2.86% |
| Endophthalmitis | 2 | 2.86% |
| DMD+VH | 1 | 1.42% |
| Asteroid hyalosis | 1 | 1.42% |
| Amblyopia | 1 | 1.42% |
| Expulsive hemorrhage | 2 | 2.86% |
| IOL drop, latter RD noted | 1 | 1.42% |
| Vitreous condensation | 1 | 1.42% |
| Cause not mentioned in file | 3 | 4.28% |
| Total | 70 | 100.00% |
Category-wise visual outcome was also compared between consultants, long-term fellows, and short-term fellows at 3 months, and the difference was not found to be statistically significant (P = 0.295), as shown in Table 11.
Table 11.
Final vision 3 months post surgery according to designation of surgeon
| Designation Of Surgeon | Total | P | ST vs. LT | ST vs. C | LT vs. C | |||
|---|---|---|---|---|---|---|---|---|
|
| ||||||||
| Short-term Fellow | Long-term Fellow | Consultant | ||||||
| Final vision (3 months) | ||||||||
| Category 1 | 36 (87.80%) | 94 (76.42%) | 88 (70.97%) | 218 (75.69%) | 0.295 | 0.355 | 0.125 | 0.501 |
| Category 2 | 4 (9.76%) | 21 (17.07%) | 21 (16.94%) | 46 (15.97%) | ||||
| Category 3 | 1 (2.44%) | 3 (2.44%) | 5 (4.03%) | 9 (3.13%) | ||||
| Category 4 | 0 (0.00%) | 5 (4.07%) | 10 (8.06%) | 15 (5.21%) | ||||
| Total | 41 (100.00%) | 123 (100.00%) | 124 (100.00%) | 288 (100.00%) | ||||
The category of visual outcome was also compared between various surgical techniques. and the postoperative visual outcome was better after phacoemulsification (83.21% had vision in category 1) as compared to ECCE (59.26% had vision in category 1) [Table 12] and there was a statistically significant difference (P = 0.003) between ECCE and phacoemulsification [Table 13].
Table 12.
Final vision 3 months post surgery according to different types of surgery performed
| Surgery Performed | Total | P | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| ECCE | ICCE | Phaco | SICS | |||
| Final vision (3 months) | ||||||
| Category 1 | 32 (59.26%) | 3 (60.00%) | 109 (83.21%) | 74 (75.51%) | 218 (75.69%) | 0.012 |
| Category 2 | 14 (25.93%) | 0 (0.00%) | 17 (12.98%) | 15 (15.31%) | 46 (15.97%) | |
| Category 3 | 3 (5.56%) | 1 (20.00%) | 1 (0.76%) | 4 (4.08%) | 9 (3.13%) | |
| Category 4 | 5 (9.26%) | 1 (20.00%) | 4 (3.05%) | 5 (5.10%) | 15 (5.21%) | |
| Total | 54 (100.00%) | 5 (100.00%) | 131 (100.00%) | 98 (100.00%) | 288 (100.00%) | |
Table 13.
P value between various surgical techniques
| ECCE | ICCE | Phaco | SICS | |
|---|---|---|---|---|
| ECCE | - | 0.358 | 0.003 | 0.216 |
| ICCE | 0.358 | - | 0.001 | 0.157 |
| Phaco | 0.003 | 0.001 | - | 0.255 |
| SICS | 0.216 | 0.157 | 0.255 | - |
Discussion
Vitreous loss is the most common complication of cataract surgery that leads to poor visual outcome[19] and needs long visual rehabilitation time. For any institution involved in a training program for cataract surgery, a high vitreous loss rate raises ethical issues as well as issues involved with the cost and the manpower time required to manage these cases in the long run. The patient’s expectations for good visual recovery are also impeded by any type of complication during cataract surgery, with vitreous loss being the most common.[19] A recorded improvement in visual outcome was noticed over the years in cases managed by automated vitrectomy over those managed by sponge vitrectomy. Previous studies have reported a visual acuity better than 6/18 in 65%–90% of cases that were managed by standard microsurgical techniques.[20,21,22,23,24] Inadvertent posterior capsule rupture can occur in any stage of the surgery and continuation of surgery without vitreous loss management can in some cases lead to irreversible damage. Timely recognition and early preventive and conservative strategies to retrieve and prevent fragments from dropping can go a long way in the management of vitreous loss. The goal of good management has been to minimize vitreous loss, remove all vitreous tractions from the AC and the wound, and plan and execute a stable IOL implantation.[25]
The incidence of vitreous loss varied from 0% to 20% in earlier studies.[5,6,7] In our study, we found an overall vitreous loss rate of 2.03%, which is less than 3% as proposed by Jaffe,[8] as an acceptable figure for vitreous loss rate. Many studies [Table 14] have reported a higher vitreous loss rate among trainees, and a high vitreous loss rate is expected in the early learning phase of any surgery.[3,4] An operating trainee usually follows a learning curve with higher complication rates in the initial part of the surgery. This high vitreous loss rate gradually becomes better with more surgeries and experience. Randleman showed that residents have a higher vitreous loss rate in their first 80 surgeries[26] while Rogers showed the same figure to be around 60.[27]
Table 14.
Vitreous loss rate reported by learning surgeons
| Investigators | Sample Size | Vitreous Loss Rate | 95% CI |
|---|---|---|---|
| Pearson et al.[15] | 936 | 10.3% | 8%-12% |
| Thomas et al.[28] | 70 | 10% | 3%-17% |
| Cotlier and Rose[7] | 61 | 19.7% | 10%-29% |
| Allinson et al.[21] | 136 | 14.4% | 8.4%-21% |
| Browning and Cobo[29] | 25 | 9% | 0%-20% |
| Ionides et al.[24] | 1533 | 4.1% | 2%-6.7% |
| Preston and Rajiv[13] | 1400 | 4.5% | NA |
| Mihir Kothari et al.[11] | 2095 | 7.63 | 7%-8.3% |
A stepwise training program is followed in our institute. The resident is trained in a minimum of 20 large incision ECCE before he progresses to manual SICS. Once adequate competence is gained in performing manual SICS by doing at least 150 SICS surgeries, the fellow is allowed to perform phacoemulsification. A lower rate of vitreous loss in training was seen in our institute due to many factors like a structured training program and step-by-step training in the technique of ECCE, SICS, and then phacoemulsification—a completely monitored surgical training program and an International Council of Ophthalmology (ICO)-Ophthalmology Surgical Competency Assessment Rubric (OSCAR) system based surgical evaluation system for the trainee. A good case selection, availability of a consultant to supervise on a one-on-one basis for all training cases, and availability of a posterior segment surgeon for dropped nucleus or nucleus fragments are the important factors involved to minimize complications. All cases are preoperatively screened by a consultant and accordingly assigned for training. Young patients, shallow AC, lens-induced glaucoma, and cases with corneal scars or coexisting ocular diseases which might affect the vision later are not assigned for training. According to the literature, implementation of a structured surgical curriculum also results in a statistically significant reduction in sentinel event complications, even after adjusting for the surgical experience.[27]
Whenever there was vitreous loss, it was managed by a consultant monitoring the surgery using a standard microsurgical technique through automated vitrectomy and an intraocular lens was put in the sulcus or bag after complete vitrectomy. If capsule support was found to be insufficient then an anterior chamber lens was put in. In some patients, a primary IOL was not placed either due to a lack of capsular support for putting a sulcus-supported IOL or because of a shallow AC or a decompensated cornea making it unsuitable for ACIOL insertion. These cases were planned for secondary IOL implantation later only if visual acuity was improving with correction. In a patient with nucleus/epinucleus drop during surgery, immediate vitreoretinal consultant was taken and further managed by the vitreoretinal consultant.
According to literature, even if managed well a vitreous loss is associated with higher morbidity and poor visual outcome and a longer hospital stay as compared with uncomplicated cases.[19]
However, in our study vitrectomy was done by an experienced surgeon to ensure complete anterior vitrectomy. The poor visual outcome also results if unskilled hands perform vitrectomy and are also associated with complications. We also teach vitrectomy to our long-term fellows in a stepwise manner. Risk evaluation before cataract surgery is extremely important and patients with an established risk factor for vitreous loss should be operated on by a more experienced surgeon.[30]
The most common cause of poor visual outcomes seen in our study was corneal edema and CME. It should be noted that both of these conditions are known to occur with increased frequency in prolonged or complicated surgeries. Thus, the poor visual outcomes of these patients can be directly attributed to the posterior capsule tear and vitreous loss. One of the interesting findings of our study has been the lower rate of vitreous loss in long-term fellows as compared to short-term fellows and consultants. As explained earlier, the long-term fellow stays in the hospital for a longer period. During their training period only when he has mastered one type of cataract surgery is he allowed to graduate to the next level, thus giving him ample exposure and experience. Long-term fellows in their tenure are more likely to master the skills of an efficient vitrectomy as compared to short-term fellows. The quantitative analysis of all trainees is done by a scoring system after every surgery. This scoring system allows the anticipation of risks in any surgical procedure. Thus, segregating the training surgeons based on their skills and probable complications.
The major drawback of our study was the inability to find out the stage at which the complication occurred in the surgery. Even though it was not the primary aim of the study, analysis of such data would have helped in knowing the steps that need more monitoring and training. Another limitation of the study was that the data was collected in the period of 2011 to 2014. With the newer advanced phaco machines, the rates of complications can be lesser if the study was to be done now.
Conclusion
In conclusion, in an institute with a structured training program for residents/trainees, the vitreous loss rate is low during cataract surgery, and if managed well and at an appropriate time with the standard microsurgical technique by an experienced hand, the visual outcome also improves post surgery.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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