Hypermature Cataracts May Be Addressed Using Manual Small Incision Surgical Approach

Manual small incision cataract surgery (MSICS) is relatively safe for eyes with hypermature cataracts (HMC) and yields adequate visual outcomes, according to a single center retrospective study published in the Journal of Cataract and Refractive Surgery.

Patients (N= 105; n=114 eyes) with HMC who underwent MSICS at Aravind Eye Hospital in India in 2019 were retrospectively reviewed for surgical and postoperative complications and visual outcomes at 1 month on the basis of preoperative risk factors.

The study population consisted of 61.9% women (48.6% aged 45-60 years, 39% were aged 61-75 years, 12.4% were aged >75 years). Approximately half (52.4%) had left laterality HMC, and 57.1% could only detect hand movement prior to surgery.

Preoperative risk factors included phacodonesis (28.6%), phacolytic glaucoma (6.7%), pseudoexfoliation (5.7%), and lens induced uveitis (4.7%).

During the surgery, patients required aphakia (6.7%), primary sulcus (5.7%), and primary iris claw (1.9%) implantations.

Intraoperative complications included zonular dialysis (6.7%), posterior capsular rent (3.8%), and whole bag removal (3.8%). Postoperative complications of corneal edema (10.4%), high intraocular pressure (IOP) on day 1 (10.4%), intraocular lens (IOL) decentration (1.9%), and residual cortex (0.9%) were observed. Five eyes received secondary intraocular lenses (IOLs) (scleral fixated lens n=3; iris claw n=2).

Stratified by the presence of pre-existing risk factors (n=30) and no risk factors (n=75), all of the no risk factor cohort had successful primary IOL implantation compared with 76.7% of those with risk factors (P <.001). The rates of corneal edema (6.7% vs 20%; P =.045), high IOP on day 1 (6.7% vs 20%; P =.045), and IOL decentration (0% vs 6.7%) were lower among the cohort without risk factors compared with the risk factor cohort, respectively.

Stratified by age, the proportion of patients with zonulopathy increased with age from 15.7% among those aged 45 to 60 years, 39.0% among those aged 61 to 75 years, and 46.1% among those older than 75 years (P =.016). A similar trend was observed for the proportion of patients with complications from 5.9% to 14.6% and 30.8% (P =.044) for the same age groups, respectively.

At preoperative day 1, 66.7% of patients had best-corrected visual acuity (BCVA) of 20/40 or better. By day 30, 93.3% had BCVAs of 20/60 or better.

The results of this study may not be generalizable as the surgeries were performed by practiced surgeons with more than 5 years of experience.

These data indicated that a MSICS approach for HMC was found to have acceptable safety and visual outcomes, especially among younger patients with no preexisting risk factors. The study authors advised, “A thorough preoperative evaluation and adequate planning is essential in these cataracts since the outcome largely depends upon the preoperative risk factors. In addition good preoperative patient counseling can avoid high patient expectations and can help plan a 2-staged procedure.”