Clinical analysis of complications during manual small incis
作者：Ning Bao, Li-Ming Tao,Wei-Jie Fan, Ti Chen
【摘要】 AIM: To discuss the cause and management of complications during the manual small incision cataract surgery (MSICS). METHODS: Manual small incision cataract surgery combined with intraocular lens implant (MSICS-IOL) were done in 160 patietns with cataract. In this paper, we reviewed the clinical data of the intraoperative complications. RESULTS: Complications including cornea injury, iris injury, posterior capsule rupture, iris prolapse and hyphema, were mainly caused by inexpert skill and lacking of experience. CONCLUSION: Mastering the indication and operating techniques, careful operation could decrease the incidence of complications during MSICS operation. By proper management, the intraoperative complications could be solved satisfactorily.
【关键词】 cataract
INTRODUCTION
MSICS-IOL is highly praised by clinical oculist in recent years for its shorter operation time, better cured effect and higher safety than traditional extracapsular cataract extraction (ECCE)[1 2]. Moreover, it does not need special equipments. But patients will still feel uncomfortable if operator could not correctly prevent and manage intraoperative complications. In this article, we reviewed 160 operations carried out in our hospital from Jan-2004 to Dec-2004 to investigate the possible causes of operation complications. Prevention and effective management of complications was discussed too.
MATERIALS AND METHODS
Materials One hundred and sixty cases (lefe eye: 85; riht eye: 75) were collected. Relative subjects aged from 7 to 89 yrs (mean=51.4 yrs). The etiology varied among these 160 eyes: 93 age-related cataracts, 40 traumatic cataracts, 12 diabetic cataracts, 5 complicated cataracts, 3 congenital cataracts and 7 for unknown reason. Among them, 123 eye's vision were less than 0.1; 33 eye's vision were 0.1 to 0.3 and the rest 4 eye's vision were more than 0.3 before operation. All of the patients were prescribed general physical and ophthalmological examinations.
Methods When peribulbar anesthesia was accompli- shed, the eyes were softed by manual ocular compress- ion. After a conjunctival flap based fornix was created, an anodic 5-6mm scleral frown incision was made. Then anterior chamber was pricked into at 12 o'clock(points), and viscoelastic was injected into it. After continuous curvilinear capsulorhexis (CCC) or can- opener capsulectomy was made, hydrodissection was performed. The nucleus was prolapsed into the anterior chamber. Then internal wound was enlarged as fan-shaped, viscoelastic was injected to superior and inferior of nucleus. The nucleus was expulsed by using normotopia crook and affusion snare (splitting nucleus if necessary). After cleaning the cortex, viscoelastic was injected to capsule bag again, and PCIOL was implanted. At last viscoelastic was replaced. The incision could be closed by itself or should be sutured if necessary.
RESULTS
Naked Vision a Week after Operation Among all these 160 cases, 14 eye's naked vision was more than 1.0; 21 eye's naked vision was from 0.8 to 1.0; 65 eye's naked vision was from 0.5 to 0.8; 39 eye's naked vision was from 0.3 to 0.5 and the rest 21 eye's naked vision was less than 0.3.
Complications During Operation Complication occurred in 35 cases: 12 eyes with corneal endothe- lium; 16 eyes with posterior capsule rupture; 9 eyes with hyphema and iris injure; 8 eyes with prolapse of iris.
DISCUSSION
MSICS was invented by Akira Momose in Japan[3]. By using sclera tunnel incison, wound could be closed itself. Anterior chamber exists all the time and IOP is stable relatively, so intraocular manipulation is safer than other methods (for example traditional ECCE). Intraoperative complication management is very important for better outputs. We will discuss in detail each complication below.
Corneal Endothelium Injury This complication is mainly caused by shallow anterior chamber or improper manipulation. Corneal endothelium is often injured during the course of appliance entering or expulsing nucleus. Corneal bedewing is common after operation, often occurs in superior cornea, primarily because of serious injure on the internal wound caused by manipulation of expulsing or splitting nucleus, aspirating cortex and transplanting IOL. Unskilled manipulation; lacking viscoelastic; appliance and nucleus touching (corneal endothelium) can also cause corneal bedewing, and we shall also pay attention to quality of irrigating solution, time and flow of irrigation as well as the cleanness of degerm soak. In MSICS, splitting nucleus is performed in anterior chamber, which may bring more probability of corneal endothe- lium injury. However, according to Maheu et al.[4], the loss rate of corneal endothelium cells does not increase significantly as opposed to other methods under proper and careful manipulation with adequate viscoelastic.
Iris Injury Iris injures mainly occurred at 6 o'clock and incision vicinity. Iris is often clipped between snare and nucleus, consequently, the root of iris is easy to be mutilated when expulsing nucleus. Iris injure can also be caused by dragging iris when aspirating cortex or fierce manipulation when transplanting IOL. We should suture the root of iris if injury is serious.
Hyphema Blood will flow to anterior chamber if the incision leans to the sclera. Iris injure can also cause hyphema. We should close incision temporarily, use rinse solution fortified with adrenalin (1:100000) to douche anterior chamber, and draw off blood and sludged blood. Most hyphema will stop after douche and operation can then go on.
Prolapse of Iris There was repeated prolapse of iris in 12 cases. Internal wound of sclera tunnel incision leaning to fornix is the reason of 10 cases, and the other 2 cases should be attributed to be short of cooperation and high posterior chamber pressure. Besides, prolapse of iris can also occur on condition of high perfusion pressure. Amydriasis caused by iris irritation makes operation more difficult. To avoid prolapse of iris, internal wound of sclera tunnel incision should enter transparent cornea for 1.5-2.0mm, and iris should be restituted as possible as we could. Because repeatedly irritating iris leaded to iris pigment loss and iris inflammation, we should aspirate cortex through side incision first, and restitute iris after IOL was implanted immediately. At last, perfusion pressure should be cared. The distance from the plane of perfusion fluid to the eye should be maintained from 40cm to 60cm. Posterior Capsule Rupture (PCR) and Prolapse of Vitreous Posterior capsule rupture is one of the severe intraoperative complications in MSICS, which affect operation output a lot.. Expedient management leads better rehabilitation and postoperative visual acuity[5].The main reasons are:①Unsatisfactory control on intraocular pression(IOP). ② In capsulorhexis, anterior capsule rupture extending backward and fierce capsulotomy can cause posterior capsular rupture or zonular dialysis. ③PCR in nucleus extraction. It is the most difficult part in MSICS to extract nucleus into anterior chamber and extract it out of the eye through the tunnel incision. Mis-operation often leads to posterior capsular rupture as well as will increase corneal endothelium injure. ④PCR in cleaning lens cortex. It is common for novice surgeon to regard nucleus extraction as the end of the operation, however, many cases of PCR do occur in aspiration/irrigation.⑤ PCR in IOL implantation. Unskilled implantaion or adjustment can also lead to PCR or zonule lesion.
Once PCR occurs, timely management is vital:① Maintaining IOP to stabilize vitreous. ② Preventing posterior capsule rupture expended; Aspirate the residual cortex as possible as we can.③When prolapse of vitreous is serious, anterior vitrectomy is necessary. ④When posterior capsule rent is smaller than 1/3quadrant, posterior chamber IOL should be still implanted into the capsule bag; but when posterior capsule rent is larger than 1/3quadrant, IOL should be implanted into the ciliary groove[6].
To reduce the incidence of intraoperative complica- tions, we should be careful for the following aspects: ① Extending incision when it is difficult to expulse nucleus.②Applying proper capsulotomy according to patient's status. When too small continuous curvilinear capsulorhexis hinders nucleus extraction, capsulotomy should be made along some meridian[7]. ③Side incision, often at 4 or 8- o'clock of transparent cornea, could facilitate nucleus prolapsing, splitting, extraction and cortex aspiration close to the incision.
MSICS could provide faster rehabilitation and need no phaco equipment. With the improvement of surgical skill, the incidence of intra- or postoperative complications will be reduced greatly. MSICS will take the place of traditional ECCE, especially in developing country.
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