Community Eye Health

JournalVOLUME 21 | ISSUE 65 | MARCH 2008 Cataract complications E DITORIAL David Yorston Consultant Ophthalmologist, Tennent Institute of Ophthalmology, Gartnavel

Hospital, 1053 Great Western Road, Bellers/ICEH Lance Glasgow G12 0YN, Scotland. Any eye surgeon, no matter how experienced, will occasionally encounter a serious cataract complication. Although complications may be devastating for the patient and are always distressing for the surgeon, are they really a major issue for VISION 2020? The evidence says that they are. Impact We know from numerous population-based surveys that a significant number of cataract operations may have poor outcomes (defined as presenting visual acuity of less than 6/60). Poor outcomes are distressing or disappointing for patients. They reflect badly on the health or surgical facility and on the surgical team. Poor outcomes may also affect the sustainability of services; they discourage other patients from coming for surgery and make patients even more Cataract surgery. ETHIOPIA reluctant to contribute towards the cost of cataract operations. the necessary aphakic correction spectacles. for the patient. In general, poor vision after cataract Problems of selection can be addressed There are currently no comprehensive surgery is caused by: inadequate correction by careful pre-operative evaluation, which figures on the proportion of poor outcomes of post-operative refractive error (lack of should reduce the number of poor results of cataract surgery in developing countries spectacles); failure to detect pre-existing due to the presence of other eye diseases. and on the relative importance of spectacles, eye conditions, e.g. macular degeneration This will help to prevent complications. selection, and surgery (Table 1, page 2, or amblyopia (selection); or surgical Surgical complications, which are the provides data from Bangladesh,1 Kenya,2 complications (surgery). main focus of this issue, can to some and Pakistan3). At a conservative estimate, The widespread adoption of intraocular extent be prevented by good practice and at least 25% (or 1.5 million) of the six lenses is starting to decrease the number of surgical technique. When complications do million cataract operations performed patients left functionally blind after cataract occur, proper management is crucial to annually in developing countries will have surgery because they are not able to obtain reduce the possibility of a poor outcome Editorial continues overleaf ➤

In This Issue 9 Endophthalmitis: controlling infection before 17 Reducing the risk of and after cataract surgery infection: hand washing EDITORIAL Nuwan Niyadurupola and Nick Astbury technique 1 Cataract complications Sue Stevens David Yorston 11 Using intracameral cefuroxime as a prophylaxis for endophthalmitis REPORT ARTICLES David Yorston; P Barry et al 18 Meeting the needs of 4 Small incision cataract surgery: 12 Recognising ‘high-risk’ eyes before cataract surgery children with congenital tips for avoiding surgical complications Parikshit Gogate and Mark Wood and developmental Reeta Gurung and Albrecht Hennig cataract in Africa 6 Management of capsular rupture and HOW TO Paul Courtright vitreous loss in cataract surgery 14 Administering an eye anaesthetic: principles, 20 USEFUL RESOURCES Nick Astbury, Mark Wood, Sewa Rural Team, techniques, and complications Yi Chen, Larry Benjamin, and Sunday O Abuh Ahmed Fahmi and Richard Bowman 20 NEWS AND NOTICES

Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 1 Community Eye Health EDITORIAL Continued

Journal Table 1. Causes of poor outcomes (presenting vision <6/60) Supporting VISION 2020: The Right to Sight Percentage of total Cause of poor outcomes The journal is produced in number of operations collaboration with the leading to a poor outcome Spectacles Selection Surgery World Health Organization Bangladesh 28% 37% 41% 22% | | Volume 21 Issue 65 March 2008 Kenya 22% 34% 36% 30% Editor Elmien Wolvaardt Ellison Pakistan 34% 36% 39% 25% Editorial committee Dr Nick Astbury (special advisor for Issue 65) Professor Allen Foster poor outcomes. About one quarter of these 0.14%.6 At Aravind Eye Hospital, in India, Dr Clare Gilbert poor outcomes are due to surgical compli- this incidence is about 0.05%.7 Dr Murray McGavin cations. Over 375,000 people can therefore The causes of endophthalmitis might vary Dr Ian Murdoch Dr GVS Murthy suffer permanent visual impairment every with geography. In most European studies, Dr Daksha Patel year as a result of surgical complications. Staphylococcus epidermidis is the most Dr Richard Wormald This means that surgical complications, common infecting microorganism. This Dr David Yorston and cataract complications in general, bacterium is found in normal eyelid skin and Regional consultants represent a significant obstacle to the conjunctiva, and it enters the eye during Dr Sergey Branchevski (Russia) success of any blindness prevention Dr Miriam Cano (Paraguay) surgery. However, in South India, Nocardia Professor Gordon Johnson (UK) programme. The topics discussed in this species were the commonest cause of Dr Susan Lewallen (Tanzania) issue are therefore vital to the successful infection.7 When endophthalmitis does occur, Dr Wanjiku Mathenge (Kenya) implementation of VISION 2020. the prognosis is grim. In the UK, one third of Dr Joseph Enyegue Oye (Francophone Africa) Dr Babar Qureshi (Pakistan) patients who suffered this complication had Dr BR Shamanna (India) Important complications a final visual acuity (VA) of less than 6/60, Professor Hugh Taylor (Australia) and 13% had lost all light perception.6 At Many things can go wrong during or immedi- Dr Min Wu (China) Aravind Eye Hospital in India, 65% of eyes Dr Andrea Zin (Brazil) ately after cataract surgery. It is impossible to had VA <6/60.7 However, these figures also address every single complication in one issue Advisors show that the prognosis following endoph- Dr Liz Barnett (Teaching and Learning) of the journal, so we have concentrated on thalmitis is by no means hopeless. Catherine Cross (Infrastructure and Technology) those that we feel are important. Dr Pak Sang Lee (Ophthalmic Equipment) Sue Stevens (Ophthalmic Nursing) What is an important complication? Some complications are common, but their impact Preventing complications Editorial assistant Anita Shah Copy editing Dr Paddy Ricard is relatively minor. Others are rare but have a We know that certain eyes are more likely to Design Lance Bellers devastating impact. The articles in this issue suffer complications than others (see article Printing Newman Thomson will focus primarily on capsular rupture and on page 12). It is therefore very important to Online edition Sally Parsley vitreous loss, which is relatively common and detect these conditions before surgery. For Email [email protected] potentially serious, and on endophthalmitis, example, eyes with endothelial dystrophy Information service which is rare but devastating. (such as Fuch’s dystrophy and corneal Jenni Sandford Does capsular rupture and vitreous loss dystrophy), pseudoexfoliation, mature Email [email protected] matter? Even in well-equipped teaching cataracts, or high ametropia (>6 dioptres of Website hospitals in the United Kingdom, vitreous myopia or hypermetropia) are all at greater Back issues are available at: loss is associated with a nearly fourfold risk than eyes without these features. www.cehjournal.org greater risk of a poor visual outcome.4 In Simple scoring systems have been devised Subscriptions operating theatres without vitrectomy to stratify patients into low, medium, and 8 Community Eye Health Journal equipment, the risk of a poor outcome is likely high risk. International Centre for Eye Health to be even higher. However, not every patient It is important to collect data in order to London School of Hygiene and Tropical Medicine, who suffers capsular rupture and vitreous identify patients at risk and to monitor their Keppel Street, London WC1E 7HT, UK. Tel +44 207 612 7964/72 loss experiences a poor outcome. If the management before and after surgery. Even Fax +44 207 958 8317 complication is managed well, it is possible to where the incidence of complications is low, Email [email protected] retain excellent vision (see article on page 6). regular collection of data helps to identify The Community Eye Health Journal is published four In high-income countries, the incidence high-risk patients and to confirm that they times a year and sent free to applicants from of capsular rupture and vitreous loss are being managed appropriately. low- and middle-income countries. French, appears to be declining and is now in the Monitoring of cataract surgical outcomes is Spanish, and Chinese translations are available and a special supplement is produced for India (in English). region of 1–2%. This improvement may be associated with a reduction in the incidence 9 Please send details of your name, occupation, and related to the use of phacoemulsification of surgical complications. postal address to the Community Eye Health Journal, and to earlier intervention, which means Some risk factors are intrinsic to the at the address above. Subscription rates for applicants that the great majority of cataracts are now patient and, short of avoiding surgery elsewhere: one year UK £50; three years UK £100. Send credit card details or an international cheque/ removed before they are mature. In low- and altogether, very little can be done to banker’s order made payable to London School of middle-income countries, however, the eliminate them. However, in the event of Hygiene and Tropical Medicine to the address above. incidence of capsular rupture and vitreous surgery, high-risk cases should be operated © International Centre for Eye Health, London loss appears to be higher.5 This is probably on in an appropriate setting, by a surgeon Articles may be photocopied, reproduced or translated provided these are not used for commercial or personal profit. Acknowledgements due to the greater complexity of many who has the right level of experience. It has should be made to the author(s) and to Community Eye Health Journal. Woodcut-style graphics originally created by Victoria Francis. Graphic on cataract operations in developing countries, been shown that surgery carried out in eye page 68 by Teresa Dodgson, all others by Victoria Francis. camps, or by an inexperienced trainee, is ISSN 0953-6833 rather than to specific deficiencies of The journal is produced in collaboration with the World Health training, expertise, or equipment used. more likely to result in complications than Organization. Signed articles are the responsibility of the named authors alone and do not necessarily reflect the policies of the World Health Vitreous loss also increases the risk of surgery undertaken in hospital by an experi- Organization. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall endophthalmitis, the most feared compli- enced surgeon. Therefore, if patients with not be liable for any damages incurred as a result of its use. The mention of specific companies or of certain manufacturers’ products does not imply cation of intraocular surgery. The incidence high-risk eyes are identified, they should be that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. of endophthalmitis may vary. Studies from operated on by a fully trained surgeon, Europe give the estimated incidence as preferably in a base hospital.

2 Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2005 Although intrinsic risk factors cannot be seems to offer the best hope of visual recovery. can only be learnt by practicing under the avoided, other factors which may increase With immediate use of intravitreal antibi- supervision of a more experienced surgeon. the risk of surgical complications are related otics, some eyes will recover useful vision. However, although vitreous loss is most to the delivery of the surgery. These latter Because complications can and will likely to occur while the surgeon is inexperi- risks can, and should, be modified. Much occur, even in the best of cases, the eye enced, when it does occur, the trainer will can be done before and during surgery to care team must be prepared to manage usually take over. This means that, in some reduce the rate of complications. them efficiently. Being prepared means: developed countries, ophthalmologists may Meticulous sterilisation of all surgical being trained to manage the problem; do a few hundred cataract operations during instruments and fluids, and careful aseptic knowing where the relevant supplies are their training, but will only manage vitreous technique, are of course essential. Articles kept; having the right drugs and equipment loss two or three times. in this issue describe important steps to on hand; and ensuring that the entire team Our training programmes rightly emphasise avoid complications during small incision is aware of the protocols for dealing with a the avoidance of complications in cataract cataract surgery (page 4) and complication. For example, surgery. However, we need a greater emphasis how to reduce the risk of there should be a protocol for on the correct management of these endophthalmitis (page 9). ‘We should vitrectomy in case of vitreous complications when they do occur, as they Recently, a large randomised maintain a loss, and appropriate inevitably will. No trainee is truly competent clinical trial has shown a equipment should be on site. to operate on cataract patients independently substantial reduction in the risk culture that If phacoemulsification is being unless, for example, they are also competent of endophthalmitis if 1 mg of used, a protocol is needed to in the management of vitreous loss. cefuroxime is injected into the values deal appropriately with dropped anterior chamber at the nuclei. When this complication Conclusion conclusion of surgery (see outcome as is managed by prompt vitrectomy abstract and comment on page highly as and fragmentation of the In conclusion, the surgeon’s first responsi- 11). This technique should be nucleus, the outcomes are bility is to prevent complications. However, adopted universally, as it has the output’ normally good. However, if the despite our best efforts, they will occur. Our potential to save the sight of nuclear material is not next priority is to ensure that we are prepared thousands of people per year. removed, the eye will be to deal with these complications effectively blinded by a combination of severe inflam- so that our patients can obtain good vision, regardless of what went wrong during surgery. The importance of mation and glaucoma. No eye clinic should be using phacoemulsification unless they If we improve our management of complica- managing complications have identified a facility to which they can tions, we can be certain that we will reduce With all complications, including capsular refer patients for vitrectomy and fragmen- the number of poor visual outcomes and rupture and vitreous loss, and even endoph- tation of a retained nucleus. As disappointed cataract patients. thalmitis, the prognosis is better if the phacoemulsification becomes more In striving to reach the goals of VISION 2020, complication is managed effectively. common in low- and middle-income we must be careful to maintain a culture that Not every patient who suffers capsular countries, the number of dropped nuclei values outcome (the quality of cataract rupture and vitreous loss experiences a poor will also increase. Dislocation of fragments operations) as highly as output (the number outcome. If the complication is managed of the lens nucleus into the vitreous occurs of operations performed). well, it is possible for the patient to retain in approximately 0.3% of phacoemulsifi- References excellent vision. However, we often do not cation operations. The incidence may be 1 Bourne RR, Dineen BP, Ali SM, Huq DM, Johnson GJ. Outcomes of cataract surgery in Bangladesh: results deal with vitreous loss as well as we should. higher in low- and middle-income countries, from a population based nationwide survey. Br J The article on page 6 provides top tips from where dense cataracts and pseudoexfo- Ophthalmol 2003;87: 813–9. experienced cataract surgeons for liation are more common.10 2 Mathenge W, Kuper H, Limburg H, Polack S, Onyango O, Nyaga G et al. Rapid assessment of avoidable managing vitreous loss. In the case of The management of complications blindness in Nakuru district, Kenya. Ophthalmology endophthalmitis, early recognition and needs to be incorporated into training 2007;114: 599–605. prompt treatment with intravitreal vanco- programmes. For example, management of 3 Bourne RRA, Dineen B, Jadoon MZ, Lee PA, Khan A, Johnson GJ, Foster A, Khan D. Outcomes of cataract mycin and either ceftazidime or amikacin vitreous loss, like every other surgical skill, surgery in Pakistan: results from the Pakistan National Blindness and Visual Impairment Survey. Br J Ophthalmol 2007;9(4): 420–6. 4 Ionides A, Minassian D, Tuft S. Visual outcome

K Hennig K following posterior capsule rupture during cataract surgery. Br J Ophthalmol 2001;85: 222–4. 5 Kothari M, Thomas R, Parikh R, Braganza A, Kuriakose T, Muliyil J. The incidence of vitreous loss and visual outcome in patients undergoing cataract surgery in a teaching hospital. Indian J Ophthalmol 2003;51: 45–52. 6 Kamalarajah S, Silvestri G, Sharma N, Khan A, Foot B, Ling R et al. Surveillance of endophthalmitis following cataract surgery in the UK. Eye 2004;18: 580–7. 7 Lalitha P, Rajagopalan J, Prakash K, Ramasamy K, Prajna NV, Srinivasan M. Postcataract endophthalmitis in South India: incidence and outcome. Ophthalmology 2005;112: 1884–9. 8 Muhtaseb M, Kalhoro A, Ionides A. A system for preop- erative stratification of cataract patients according to risk of intraoperative complications: a prospective analysis of 1,441 cases. Br J Ophthalmol 2004;88: 1242–6. 9 Limburg H, Foster A, Gilbert C, Johnson GJ, Kyndt M, Myatt M. Routine monitoring of visual outcome of cataract surgery. Part 2: Results from eight study centres. Br J Ophthalmol 2005;89: 50–2. 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 Skin cleaned with povidone-iodine (Betadine 10%) before a cataract operation. NEPAL 2005;112: 869–74.

Copyright © 2008 David Yorston. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. SMALL INCISION CATARACT SURGERY Small incision cataract surgery: tips for avoiding surgical complications Reeta Gurung Deputy Medical Director, Tilganga Eye hand washing (see ‘how to’ article on page should always be parallel to the sclero- Centre, Kathmandu, Nepal. 17), the use of sterile instruments, the corneal plane. Email: [email protected] ‘non-touch’ technique, the subconjunctival • Judge the depth of half-thickness sclero- injection of antibiotics,4,5 and the intracameral corneal tunnel incisions by observing how Albrecht Hennig injection of cefuroxime6 at the end of surgery clearly you can see the crescent knife Programme Director, Eastern Regional (see article on page 11). The dose of intra- during the incision (Figure 4). If the Eye Care Programme, Lahan, Nepal. cameral cefuroxime must be meticulously Email: [email protected] crescent knife can be seen very clearly, prepared, as no commercially made prepa- this indicates that the scleral layer is very Small incision cataract surgery (SICS) is one ration is available (see box on page 11). thin and that the crescent knife might of the cataract surgical techniques commonly perforate to the outside. (causing what is used in developing countries. This technique Tunnel construction known as a ‘buttonhole’) • A buttonhole can be corrected by making usually results in a good visual outcome and Tunnel size 1–3 a deeper ‘frown’ incision and dissecting is useful for high-volume cataract surgery. The expected size and density of the nucleus the tunnel in a deeper plane, starting at This article describes how to minimise should determine the size of the tunnel. For the opposite side of the buttonhole.7 surgical complications in SICS. example, the extraction of immature cataracts • If the crescent knife is not visible during in younger patients may only require a small the incision, this indicates that you are Before you begin tunnel, just large enough for the intraocular working too deeply inside the sclera; you lens (IOL) optic to pass through. Very big, may perforate towards the anterior brown nuclei require a larger tunnel size. chamber’s angle (a ‘premature entry’). These nuclei can sometimes be up to 8 mm • A premature entry could lead to surgical in diameter and 4 mm thick. However, a large complications, such as iris trauma or irido- tunnel need not be a problem: even larger dialysis, iris prolapse, and a tunnel which Nuwan Niyadurupola Nuwan tunnels are self-sealing and don’t need is not self-sealing. suturing if they are prepared correctly. If there • Manage a premature entry by starting a is doubt about the self-sealing effect, the more shallow dissection at the other end surgeon may apply one or two sutures at the of the tunnel. Suturing of the wound is end of surgery. If correctly tied, these will, at required at the end of surgery.7 the same time, reduce any induced astig- Figure 1. Instilling povidone-iodine matism. Opening of the anterior (Betadine) 5% eye drops Constructing the tunnel capsule • Only a correct sclerocorneal tunnel This can be done by different techniques incision, at least 1 to 2 mm into the clear K Hennig K (such as linear capsulotomy (Figure 5), the cornea, leads to a self-sealing wound. ‘can-opener’ technique, and triangular or • Scleral cauterisation before tunnel. V-shaped capsulotomy) or by capsulorhexis. construction reduces the risk of pre- and Capsulotomies are easy to perform, but postoperative hyphaema. may lead to uncontrolled capsular tear • Sharp tunnel instruments (such as the extension, posterior capsule rupture, crescent knife and keratome) should be vitreous loss, and IOL decentration. These used to construct the tunnel. A blunt problems can be avoided by a careful hydro- keratome could cause stripping of dissection, especially in patients with Descemet’s membrane. posterior polar cataract or posterior lenti- Figure 2. Skin around the eye cleaned • Stabilising the sclera with toothed forceps conus (hydrodissection is most effective if with povidone-iodine (Betadine) 10% makes tunnel construction easier (Figure the fluid is injected directly into the 3). However, in order to avoid tunnel capsule7). Keeping instrument manipulation damage and leakage, the forceps should Before you begin to a minimum during surgery will also help not be used on the tunnel flap. you to avoid posterior capsule rupture. With SICS, as with all cataract surgery • With a half-thickness sclerocorneal tunnel The best capsular opening is a techniques, it is mandatory to perform a incision, the direction of the crescent knife continuous curvilinear capsulorhexis (CCC): thorough preoperative assessment of the patient (see article on page 12). This will Tunnel construction allow the surgeon to prepare for anticipated complications – for example, a dislocated or

subluxated lens – and to plan the operation Hennig K Hennig K accordingly. Prepare the patient in the following way: • Wash the patient’s face. • Instil povidone-iodine (Betadine) 5% aqueous eye drops (Figure 1). • Clean the skin around the eye with povidone-iodine 10% (Figure 2). Other measures will also help to reduce the Figure 3. Stabilising the sclera with Figure 4. Making the sclerocorneal tunnel toothed forceps incision risk of postoperative endophthalmitis: proper

4 Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 Opening of the anterior capsule nucleus delivery.These instruments should push slightly posteriorly, which will help to open the incision for easier nucleus delivery

K Hennig K Hennig K (Figures 9 & 10). In addition, gently pulling the bridle suture makes nucleus delivery through the tunnel easier. Removal of the cortex Most of the lens cortex can be removed with a Simcoe cannula through the tunnel (Figure 11). A sub-incisional cortex can be safely aspirated through a side port at Figure 5. Linear capsulotomy Figure 6. Continuous curvilinear 130–180˚ from the incision site.8 If capsulorhexis stripping of Descemet’s membrane occurs while cleaning the cortex, great care should it will guarantee a long-term, ‘in the bag’ IOL Difficulties with nucleus delivery are be taken not to tear it off. If this happens, air centration (Figure 6). However, CCC is more mostly due to the inner tunnel opening should be injected into the chamber at the difficult to learn. This technique sometimes being too small. This should be checked end of the operation to push Descemet’s requires staining of the capsule and the before nucleus removal, e.g. with the visco membrane against the cornea. opening also needs to be large enough for cannula (Figure 7). If there is any doubt While clearing the cortex with a Simcoe the nucleus to get through. It may therefore about the correct tunnel size, it is better to cannula, posterior capsule rupture and not be possible to use this technique in eyes further enlarge the tunnel before removing vitreous loss may occur. This can be avoided with very big nuclei and smaller pupils. In the nucleus. However, the surgeon should by carefully watching the posterior capsule. such a situation, a linear, triangular, or other avoid cutting into the anterior chamber’s Wrinkles indicate that the posterior capsule capsulotomy may be preferred. angle while enlarging the inner tunnel opening, is caught in the aspiration port of the Simcoe Failing to complete the anterior capsulotomy, as this carries an increased risk of hyphaema. cannula. This requires immediate back- making a too-small CCC, and pulling residual While lifting the nucleus into the anterior flushing to avoid posterior capsular rupture. anterior capsular tags can cause the posterior chamber (Figure 8), special care is required To reduce the risk of a postoperative capsule to rupture. Early recognition and in patients with pseudoexfoliation and in increase in intraocular pressure, thorough correction of these problems is very older patients with weak zonules. removal of viscoelastics is required. important to avoid further complications. While delivering the nucleus through the tunnel, accidental contact between the Removal of the cortex nucleus and the corneal endothelium must Nucleus removal be avoided. Otherwise, postoperative

During SICS, different techniques can be corneal oedema, and sometimes even Hennig K used to remove the nucleus: either hydro- corneal decompensation, may occur. expression alone (using an anterior In order to avoid such corneal problems, chamber maintainer), hydroexpression plus you must inject sufficient viscoelastic fluid extraction (using an irrigating vectis or between the lens and the cornea to protect Simcoe cannula), or extraction alone (using the endothelium. Instruments for nucleus a ‘fishhook’ needle). Problems with these removal, such as the irrigating vectis, different SICS techniques are mainly related Simcoe cannula, or fishhook, should be to the size of the tunnel and the proximity of kept away from the cornea and should not Figure 11. Removing the cortex using a the nucleus to the corneal endothelium. push the nucleus against the cornea during Simcoe cannula Nucleus removal References 1 Hennig A, Kumar J, Yorston D, Foster A. Sutureless cataract surgery with nucleus extraction: outcome of a

K Hennig K Hennig K prospective study in Nepal. Br J Ophthalmol 2003;87: 266–270. 2 Hennig A et al., World Sight Day and cataract blindness. Br J Ophthalmol 2002;86: 830–31. 3 Ruit SPG, Gurung R, Tabin G, Moran D, Brian G. An innovation in developing world cataract surgery. Clin Exp Ophthalmol 2000;28: 274–279. 4 Ng JQ, Morlet N, Bulsara MK, Semmens JB. Reducing the risk for endophthalmitis after cataract surgery: population-based nested case-control study: endophthalmitis population study of western Australia Figure 7. Checking the tunnel size Figure 8. Mobilising the nucleus before sixth report. J Cataract Refract Surg 2007;33(2): lifting it into the anterior chamber 269–80. 5 Kamalrajah S, Ling R, Silvestri G, Sharma NK, Cole MD, Cran G, Best RM. Presumed infectious endoph- thalmitis following cataract surgery in the UK: a

K Hennig K Hennig K case-control study of risk factors. Eye 2007;21(5): 580–6. 6 ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007;33(6): 978–88. 7 Schroeder B. Sutureless cataract extraction: complica- tions and management; learning curves. Comm Eye Health J 2003;16(48): 58–60. 8 Traianidis P, Sakkias G, Avramides S. Prevention and Figure 9. Inserting the fishhook needle Figure 10. Delivering the nucleus management of posterior capsule rupture. Eur J Ophthalmol 1996;6(4):379–82.

Copyright © 2008 Reeta Gurung and Albrecht Hennig. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. CAPSULAR RUPTURE AND VITREOUS LOSS Management of capsular rupture and vitreous loss in cataract surgery

Nick Astbury Consultant Ophthalmic Surgeon, Norfolk and Norwich University Hospital NHS Trust, Colney Lane,

Norwich NR4 7UY, UK. Hospital Kasturba

Every eye surgeon has experienced – or will experience – that sinking feeling when the posterior capsule is ruptured and vitreous comes forward into the anterior chamber. At that moment everything changes, including the heart rate of the surgeon and the possible outcome for the patient. But all is not lost. If the theatre team are well prepared, the situation can be managed calmly and professionally in order to achieve the best possible visual result. It is most important to remove every trace of vitreous from the wound and anterior chamber. Failure to achieve this increases the risks of leakage, of infection due to a vitreous wick, or of vitreous traction that may lead to cystoid macular oedema or retinal detachment. In an ideal world, automated vitrectomy should be the procedure of choice to deal with vitreous loss; however, if the A surgeon performs a vitrectomy after capsular rupture and vitreous loss. INDIA equipment is unavailable, it may be capsulorhexis, you should be able to necessary to resort to the ‘sponge and Tanzania insert a lens in the sulcus, as the anterior scissors’ vitrectomy method. Mark Wood rim of the capsule will hopefully still be Implanting an intraocular lens (IOL), Consultant Ophthalmologist, there. With a linear capsulotomy this may although desirable, should not be under- CCBRT Hospital, Box 23310, be possible as well. I usually insert a hard taken at any cost if it will involve further Dar es Salaam, Tanzania. lens into the sulcus and abandon any trauma to the eye. Email: [email protected] idea of using a foldable lens. If there is It is worth mentioning that pressure from enough capsule inferiorly, I use an the speculum is often to blame for the diffi- Capsular rupture is a dreaded complication Aurolab scleral fixation lens. This IOL has culty surgeons experience in dealing with of cataract surgery; it jeopardises the the advantage of having a large optic of capsular rupture and vitreous loss. chances of inserting a posterior lens and 6.5 mm which gives it added stability; it Therefore, it is always advisable to make therefore obtaining the ideal optical can be sutured with 10-0 Prolene to the sure that the speculum is not pressing on correction of the patient’s aphakia after the iris at the 12 o’clock position through the the eye. operation. However, if this complication hole in the haptic. This is not possible Below, five ophthalmologists from around does occur, do not panic: most cases can be salvaged. with small incision surgery, because you the world present their tips on managing this cannot suture the lens to the iris down a complication. Their opinions and methods Tip 1 tunnel incision. differ, depending upon individual circum- Stop everything. Sit back and think. Get stances and available resources. your vitrector ready while thinking. The Tip 4 Guerder Vitron anterior vitrectomy machine If you have done small incision surgery, is ideal and should be made available to it is more difficult to manage vitreous all cataract surgeons. You will have to loss. In this circumstance, I would perform an anterior vitrectomy. Try to probably close the eye and implant a

Kasturba Hospital Kasturba preserve as much capsule as possible secondary IOL. It is always preferable to while you do this. implant a posterior lens. However, if this is not possible, an anterior chamber lens is a Tip 2 good alternative. Do not forget to do an After you have done a vitrectomy, if you are iridectomy. I perform two iridectomies not sure how much capsule remains it may when placing an anterior lens. be wise to close the incision and consider implanting a secondary IOL. Later, you can Tip 5 use the slit lamp to visualise the remaining In a patient with an only eye, do not forget Vitrectomy parameters set on a phaco capsule and plan your operation. that +10 aphakic correction spectacles machine used to perform automated can give good vision; this is better than vitrectomy after capsular rupture and Tip 3 struggling to insert an imperfect IOL which vitreous loss. INDIA If you have done a continuous curvilinear may cause more damage to the tissues.

6 Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 giving a systemic injection of mannitol India while the patient is on the operating table China Uday Gajiwala (left), may help to reduce the pressure. Yi Chen Rajesh Patel, and others People Eye Centre, Peking University in the Sewa Rural Team Tip 5 People’s Hospital, Beijing 100044, Placement of the IOL China. Sewa Rural, Jhagadia District, Bharuch, Gujarat In the case of a posterior capsular tear Email: [email protected] 393 110, India. involving less than a third of the periphery, the IOL can be placed with the haptics Tip 1 Tip 1 positioned away from the tear; the stability Stop working as soon as you sense If capsular rupture and vitreous loss occurs of the IOL should then be checked. that there is a problem. Carefully remove after complete removal of the lens matter, With a central tear and an adequate rim the instrument from the eye if possible. perform a good anterior vitrectomy (an all the way around, a sulcus-fixated IOL can Remember that an abrupt shallowing automated vitrectomy probe without in-built be implanted. The IOL can be placed in front of the anterior chamber may extend the irrigation is preferable). of the anterior capsule if the rhexis is round tear and that abrupt removal of the To prevent extension of the tear, and the rim is adequate in size. But if the instrument may lead to lens material hydration of the vitreous, and flushing of the support is less than adequate, it may be falling into the vitreous. Inject visco- vitreous, the cut rate of the vitrectomy necessary to place an anterior chamber IOL elastic fluid through the side-port incision, machine should be high (up to 800 cuts or a sclerally fixated IOL. if necessary, before removing instruments per minute) and the vacuum should be In all cases of posterior capsular tear, it is from the eye. low (approximately 50 mmHg). important to use an IOL with a large optic Tip 2 Tip 2 size (>6.0 mm) and with a large overall diameter (>13.5 mm). Maintain the anterior chamber and If capsular rupture and vitreous loss occurs stabilise the remaining lens material. while some lens matter remains, perform a Always remember: Filling the anterior chamber with good automated anterior vitrectomy and viscoelastic helps to maintain the anterior cortex removal, ensuring aspiration of the • The importance of recognising the complication as early as possible cannot chamber and may help to tamponade the cortex towards the tear and not away from anterior hyaloid face. Injecting viscoelastic it. Dry aspiration is most suitable. be overemphasised. • Do not panic, keep calm, keep to the below the remaining lens material may stabilise it. Tip 3 basic rules. Complete removal of vitreous from the • No vitreous should be left in the iris plane Tip 3 anterior chamber is indicated by a round or in front of it. If possible, remove all remaining lens pupil, the falling back of the iris, and the • ‘Sponge and scissors’ vitrectomy should material. Enlarge the incision and extract formation of a single air bubble after air be avoided if at all possible. the nucleus with a loop. If the capsular injection. • The placement of the IOL depends on the capsular support available – even if the rupture is small, the irrigation-aspiration technique may be used to aspirate the Tip 4 anterior capsule is available, a posterior remaining cortex. If the capsular rupture is Special situations chamber IOL can be implanted in the sulcus. • If the capsular tear is in the inferior • Try to do a primary IOL implant, whether large and cortex is mixed with vitreous, an position, be careful because the IOL it is an anterior chamber IOL or a sclerally anterior vitrectomy may be used to remove can drop from the tear into the vitreous fixated IOL. both the cortex and vitreous. cavity. • It is good practice to inform the patient of • If there is a bulge in the vitreous material, the complication. Tip 4 If vitreous loss has occurred, remove all vitreous from the anterior chamber and the incision. A ‘sponge and scissors’ vitrectomy can be very useful if automated vitrectomy instruments are not available; however, it is unlikely to remove all vitreous from the Nuwan Niyadurupola Nuwan anterior chamber. Automated vitrectomy is preferable.

Tip 5 Implant the IOL according to the situation. ‘In the bag’ placement is ideal. If there is a large rupture of the posterior capsule, the surgeon may implant the IOL in the ciliary sulcus. Once the IOL has been placed, gradually instil a miotic. Afterwards, remove the viscoelastic with irrigation-aspiration. Raising the irrigation bottle is important to avoid any shallowing of the anterior chamber; this will help prevent further vitreous prolapse. You must pay careful attention. In particular, check the pupil and wounds to ensure that all vitreous has been removed. Always check that the wounds are watertight. Performing a three-port pars plana vitrectomy. UK Continues overleaf ➤

Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 7 CAPSULAR RUPTURE AND VITREOUS LOSS Continued

vitreous degeneration. However, in all United Kingdom cases, vitreous loss must be carefully Larry Benjamin managed to prevent complications such as Consultant Ophthalmic Surgeon, defective wound closure, high astigmatism, Department of Ophthalmology, high or low intraocular pressure, corneal Stoke Mandeville Hospital, oedema from endothelial touch, retinal Mandeville Road, Aylesbury, Buckinghamshire, detachment, chronic inflammation, or HP21 8AL, UK. cystoid macular oedema. Tip 1 Tip 2 If vitreous loss is managed well, the outcome Management starts with good preoperative can be just as good as if it had not happened. patient education to reduce the risk of The first tip isearly recognition that patient movement during surgery. vitreous loss has taken place. The implica- Figure 1. Triamcinolone acetonide is Approximately 90–95% of our patients tions of vitreous loss may vary, depending injected into the anterior chamber to stain remain quiet during surgery without any on the type of cataract surgery. It tends to the vitreous and make it easier to see. form of premedication. be a fairly expulsive event when it occurs during extracapsular surgery, but it is less Tip 3 so during closed-chamber phacoemulsifi- Poor anaesthesia is a major contributing cation. By recognising the event early, steps factor to vitreous loss. Good anaesthesia can be taken to minimise further problems. must achieve good pain relief (analgesia) Take time to sit back for a minute and and immobilisation (akinesia) of the lids assess the situation carefully. Do not and globe (page 14). suddenly pull instruments out of the eye – this may cause vitreoretinal traction. Tip 4 Avoid undue pressure on the eye from Tip 2 the fixation forceps, speculum, or lens Keep calm and ask for the vitrector in a expressor. Avoid clumsy use of instruments quiet, level voice (as if you were simply inside the eye. Avoid creating too high a

asking someone to pass the salt). Make (both) www.medrounds.org/cataract-surgery-greenhorns – Publications Medrounds and Oetting Tom pressure when injecting the irrigating fluid sure the team environment stays calm and Figure 2. Using a vitrector. Note the vitreous into the anterior chamber. supportive. You should learn how to set up which has been stained with triamcinolone and use the vitrector before a case of acetonide. Tip 5 vitreous loss has to be dealt with. This useful device for delivering the infusion When forced to use the manual ‘sponge and experience can be gained in a skills centre. fluid. This is placed at the limbus and is scissors’ vitrectomy method: self-retaining. Tip 3 • Work with good magnification and Use triamcinolone acetonide (Kenelog) to Tip 5 illumination. stain the vitreous in the anterior chamber Postoperative follow-up is important. The • Use non-fragmenting cellulose sponges. (this is an off-label use). A solution of 40 mg patient will need to be told that a compli- • Touch the vitreous in the anterior chamber in 1 ml can be used for this purpose, neat or cation has occurred and should be informed with a sponge tip and cut the vitreous diluted twice or three times its own volume of the possible outcomes. A strands with sharp with a balanced salt solution. A gentle topical steroid, an antibiotic, and a ‘You should De Wecker’s or injection of the drug via a Rycroft cannula mydriatic should be used post- Wescott’s scissors. into the anterior chamber (Figure 1) will operatively and regular follow-up learn to set • Avoid excessive make the vitreous easier to see and help to visits should take place until the traction on the guide you: you will be able to see when all eye is quiet and further complica- up and use a vitreous. the vitreous has been removed from the tions are ruled out or managed. • Repeat the wound and pupillary area (Figure 2). If some If you did not place an implant vitrector before procedure until all triamcinolone remains in the eye, it will have during the initial operation, you a case of strands of vitreous anti-inflammatory properties; however, can make arrangements to do this are removed from the checks should be made postoperatively for at a later date. Other forms of vitreous loss has anterior chamber, iris a rise in intraocular pressure. visual correction in the short term surface, and wound (such as contact lenses) can be to be dealt with’ edges. Tip 4 discussed. You should carefully • After removing the Using a separate small wound for the inspect the retinal periphery when vitreous, sweep the vitrector prevents the main wound from the eye is quiet. The patient should be iris surface with an iris repositor to check becoming oedematous and maintains an warned about the possible symptoms of whether there is residual vitreous. If effective closed chamber. Use the vitrector retinal detachment, cystoid macular present, the pupil may be distorted. at the maximum cut rate (usually around oedema, and infection. Repeat the procedure until the pupil 400 cuts per minute on an anterior becomes round. vitrector) and make small movements of the Nigeria • A weak solution of pilocarpine (we use probe within the eye. This will minimise four drops of 4% pilocarpine in 2 ml of vitreoretinal traction during the operation. It Sunday O Abuh normal saline solution) may be instilled is a good idea to separate the infusion fluid Paediatric Ophthalmologist, ECWA Eye into the anterior chamber to constrict from the vitrector and to start the anterior Hospital, PO Box 14, Kano, Nigeria. the pupil and keep the vitreous behind vitrectomy with no fluid running. Keep the Email: [email protected] the iris. vacuum low during this step. When the Tip 1 • Re-form the anterior chamber with air infusion is started, keep the flow rate low. Vitreous loss may be inevitable in eyes that after wound closure to minimise vitreous An anterior chamber maintainer is a very have undergone couching or in cases of entrapment in the wound. Copyright © 2008 Nick Astbury, Mark Wood, Uday Gajiwala, Rajesh Patel, Yi Chen, Larry Benjamin and Sunday O Abuh. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Endophthalmitis Endophthalmitis: controlling infection before and after cataract surgery

Nuwan Niyadurupola Specialist Registrar in Ophthalmology, Department of Ophthalmology, Norfolk and Norwich University Hospital NHS Trust, Astbury Nick Colney Lane, Norwich NR4 7UY, UK. Email: [email protected] Nick Astbury Consultant Ophthalmic Surgeon, Norfolk and Norwich University Hospital NHS Trust. Endophthalmitis is a rare, but serious, postoperative complication of cataract surgery. It can have a devastating conse- quence on a patient’s vision: some patients may lose all light perception. The incidence of endophthalmitis has been reported to be between 0.13% and Endophthalmitis 0.7%.1 The primary source of this intraocular infection is considered to be bacteria from the patient’s ocular surface of endophthalmitis. The correction or treatment Preparation of the surgeon of these risk factors prior to cataract surgery (cornea, conjunctiva) or adnexa (lacrimal Proper hand washing (see page 17), 2 is desirable to reduce the risk of infection. glands, eyelids, and extraocular muscles). followed by the use of sterile gloves and The bacteria most frequently isolated are Recent immunosuppressive gowns during surgery, is accepted practice. gram-positive coagulase-negative cocci treatment and a history of immunosup- However, there has been considerable (mainly Staphylococcus epidermidis) which pression have also been shown to be discussion about the use of surgical masks. account for 70% of culture-positive cases.2 significant risk factors for endophthalmitis.4 During a study in which culture plates were Staphylococcus aureus is isolated in 10% of placed in the operative field, the wearing of culture-positive cases, Streptococcus surgical face masks was shown to significantly species in 9%, Enterococcus species in 2%, reduce bacterial cell counts.6 However, other and other gram-positive species in 3% of Astbury Nick studies have found that the use of face cases.1 Gram-negative bacteria account for masks produces no reduction in airborne just 6% of culture-positive cases; however, bacteria in theatre and no reduction in an infection with these bacteria, particularly wound infection rates in general surgery.6 with Pseudomonas aeruginosa, can lead to Other arguments for not wearing facemasks a devastating visual outcome.1,3 include: face masks increase condensation on operating microscopes, which may impair Preoperative risk factors the surgeon’s view; they may possibly cause Conditions that increase the presence of Figure 1. Preparation of the drape covering the eyelid and lashes prior to cataract surgery rubbing off of facial skin squames into the bacteria on the ocular surface are risk operative field; and they impair communi- factors for the development of endoph- cation.6 However, a recent case-control thalmitis.1 These conditions include: Preparation of the patient The meticulous preparation of the patient study showed that the use of face masks by blepharitis, conjunctivitis, cannuliculitis, the surgeon and the scrub nurse significantly lacrimal duct obstruction, contact lens wear, for cataract surgery is possibly the most important factor in reducing the risk of reduced the risk of endophthalmitis and an ocular prosthesis in the fellow orbit. (p<0.001).4 In conclusion, given the devas- Eyelid abnormalities, particularly the endophthalmitis. It has been found that the instillation of topical 5% povidone-iodine tating consequences of endophthalmitis, the presence of entropion, also increase the risk (Betadine) into the conjunctival sac prior to wearing of face masks is recommended.7 surgery significantly reduces the risk of Note: Facemasks must be worn Tips for preventing endophthalmitis; this has become accepted correctly; they must cover the nose, mouth, endophthalmitis preoperative practice.2,4 The antimicrobial and chin completely and must never hang effect of povidone-iodine occurs within one around the neck. • Instil povidone-iodine 5% eye drops minute of irrigation; it kills 96.7% of bacteria prior to surgery. and lasts for at least one hour.5 Povidone- Surgical technique and • Carefully drape the eyelid and lashes iodine appears to be more effective in intraoperative factors prior to surgery. reducing infection than preoperative anti- 1,2 Incisions • Use sterile gloves, gowns, and face masks. biotics. As the bacteria responsible for The clear corneal incisions commonly • Construct watertight incisions, endophthalmitis most commonly originate from used for phacoemulsification are associated preferably three-plane. the patient’s eyelids, careful draping of the with a significantly increased risk of endoph- • Manage complications (e.g. capsular eyelid and lashes (Figure 1) is important in thalmitis, compared to scleral tunnel rupture) effectively. reducing the presence of bacteria in the incisions.2,8 This may relate to differences • Acrylic optics are better than silicone. surgical field, which in turn reduces the risk of 1,2 in wound healing and potential wound leaks. • Inject intracameral cefuroxime endophthalmitis. The practice of trimming The incidence of a flat anterior chamber is postoperatively (1 mg in 0.1 ml normal lashes is not recommended: it does not higher with clear corneal incisions than with saline). reduce periocular bacterial flora and does not reduce the risk of endophthalmitis.5 Continues overleaf ➤

Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 9 Endophthalmitis Continued scleral tunnel incisions.2 Temporal clear The difference is more likely explained by the against endophthalmitis when it is given corneal incisions take longer to heal than interaction of biofilms with the surface of the as a subconjunctival injection at the scleral tunnel incisions and are also prone to lens.8 The material used for the IOL haptic end of surgery. Therapeutic levels of fish-mouthing and trauma, thereby allowing and the type of IOL (multipiece or one-piece) cefuroxime in the anterior chamber are access of bacteria into the eye.2 did not seem to affect the incidence of achieved after 12 to 24 minutes following The construction of a watertight corneal endophthalmitis.8 The use of injectable IOLs subconjunctival injection and levels continue incision is important in reducing the risk of has been linked with a reduced risk of to rise beyond two hours.4 There is some intraocular infection. Straight-in and two-plane endophthalmitis, possibly as a result of the evidence for this: other subconjunctival clear corneal incisions can leak; three- IOL not coming in contact with the tear film. antibiotics given at the conclusion of plane incisions are better.2 Starting the However, there is often a strong correlation cataract surgery have been found to reduce incision in the vascular region of the limbus between the type of IOL insertion (forceps or the risk of endophthalmitis.4 results in an increased fibroblastic response, injector) and the site of incision (scleral which may promote healing.2 Longer corneal tunnel or clear corneal); it is considered that Postoperative treatment incisions, in comparison to the incision it is the site of incision that is the more and follow-up width, are more stable than shorter length important risk factor.8 There is insufficient data on the effec- incisions and hence may reduce wound tiveness of the postoperative use of topical leaks and the risk of endophthalmitis.2,9 Antibiotics antibiotics in reducing rates of endoph- There is little evidence that using antibiotics thalmitis, although this is a widespread Complications in irrigating fluid during surgery can reduce pratice amongst surgeons.1 Following Surgical complications, in particular a torn the risk of endophthalmitis. Vancomycin is uncomplicated cataract surgery, the routine posterior lens capsule, can significantly the antibiotic most commonly used in review of patients on the first postoperative increase the risk of endophthalmitis.4,8 irrigating fluid, due to its activity against day is not necessary, due to the low rate of This is backed up by animal studies. In one gram-positive bacteria. However, the half-life sight-threatening complications.10 However, study on monkey eyes, the posterior of vancomycin in the anterior chamber is a review on the first day is probably recom- capsule was shown to have a barrier effect less than two hours and, for the most mended when patients have had against the development of endophthalmitis common gram-positive bacteria, it does not complicated cataract surgery, surgery on an following the inoculation of bacteria into the achieve concentrations in the anterior 4 eye with co-existing disease (such as uveitis anterior chamber. In another study, chamber above MIC90 (the concentration of or glaucoma), or surgery performed on an bacteria injected into the vitreous of rabbit the antibiotic at which 90% of bacteria are only eye and when patients do not have 1,2 eyes more readily caused endophthalmitis destroyed). Concerns about the emerging ready access to eye services.10 than bacteria injected into the anterior resistance to vancomycin, coupled with the chamber.4 The association of endoph- lack of protective effect against endoph- thalmitis with surgical complications may thalmitis of antibiotics used in irrigating fluid, Summary explain the finding that cases of endoph- has led to the recommendation that vanco- Multiple factors can lead to endophthalmitis. thalmitis are more prevalent when senior mycin should not be used intraoperatively.2,4 The source of the bacteria is considered to surgeons operate, as these surgeons may In contrast, the intracameral injection be from the patient’s own ocular surface or take on more technically difficult cases.4,8 of the antibiotic cefuroxime (1 mg in adnexa. For this reason, simple measures in 0.1 ml normal saline) at the conclusion the preparation of the patient have a Intraocular lenses of cataract surgery has caused a reduction dramatic effect on the reduction of endoph- The choice of intraocular lens (IOL) can affect in the number of cases of endophthalmitis. thalmitis rates, in particular the instillation of the risk of endophthalmitis. The use of IOLs The European Society of Cataract and povidone-iodine and careful draping to with silicone optics is associated with an Refractive Surgeons (ESCRS) multicentre isolate the lid and lashes. The use of anti- increased risk of endophthalmitis, compared study was stopped early when it was found biotics at the conclusion of surgery, with that of IOLs with acrylic optics. It is that the absence of cefuroxime adminis- especially intracameral or subconjunctival cefuroxime, is also recommended. unlikely that this is due to the hydrophobic tration at the end of cataract surgery was nature of silicone, since a comparison of associated with a five- to six-fold increase in References hydrophobic and hydrophilic lenses showed the risk of endophthalmitis8 (see page 11). 1 Mamalis N, Kearsley L, Brinton E. Postoperative no difference in the rates of endophthalmitis. Cefuroxime may also be protective endophthalmitis. Curr Opin Ophthalmol 2002;13: 14–18. 2 Buzard K, Liapis S. Prevention of endophthalmitis. J Cataract Refract Surg 2004;30: 1953–1959. Protocol for treating endophthalmitis 3 Eifrig CWG, Scott IU, Flynn HW Jr, Miller D. Endophthalmitis caused by Pseudomonas aeruginosa. • Admit the patient, stop antibiotics, and • If you cannot see the posterior segment, Ophthalmology 2003;110: 1714–1717. prepare for theatre. do an ultrasound B-scan, if this is 4 Kamalarajah S, Ling R, Silvestri G, Sharma NK, Cole MD, Cran G, Best RM. Presumed infectious endoph- • Perform a vitreous tap with or without available. thalmitis following cataract surgery in the UK: a capsulectomy. • If there is no improvement within case-control study of risk factors. Eye 2007;21: • Give an intravitreal injection of vancomycin 24 hours, consider repeating the vitreous 580–586. 5 Schmitz S, Dick HB, Krummenauer F, Pfeiffer N. 2 mg and cefuroxime (or ceftazidime) sample and the antibiotic injections. Endophthalmitis in cataract surgery: results of a 2 mg (or 0.5 mg amikacin if the patient is • Consider topical or systemic steroids if German study. Ophthalmology 1999;106: allergic to penicillin). 1869–1877. you are confident the infection is under 6 Leyland M, Bacon A, Watson SL. Risk factors for • Give a subconjunctival injection of vanco- control (i.e. pain is diminishing, fibrin is endophthalmitis: does non-wearing of facemasks mycin 50 mg and cefuroxime (or contracting, hypopyon is decreasing). increase relative risk? Eye 2007;21: 1441. ceftazidime) 125 mg (or amikacin 50 mg 7 Trivedi RH, Wilson ME Jr. As surgeons, our view of • Taper the treatment according to the postcataract surgery endophthalmitis prevention is still if the patient is allergic to penicillin). patient’s response and culture results. not clear. Eye 2007;21: 577–579. • Send the vitreous sample for microscopy • Keep the patient informed of progress. 8 ESCRS Endophthalmitis Study Group. Prophylaxis of and culture. postoperative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and • Monitor the pain experienced by the Note: Vancomycin and cefuroxime (or identification of risk factors. J Cataract Refract Surg patient. A reduction in pain suggests ceftazidime) must not be mixed in the same 2007;33: 978–988. bacterial kill. syringe – draw up in separate syringes. 9 Olson RJ. Reducing the risk of postoperative endoph- thalmitis. Surv Ophthalmol 2004;49: S55-S61. • Start instilling vancomycin 5% and Reproduced by kind permission of The Royal College of 10 Alwitry A, Rotchford A, Gardner I. First day review after ceftazidime 5% eyedrops hourly. Ophthalmologists uncomplicated phacoemulsification: is it necessary? Eur J Ophthalmol 2006;16: 554–559.

Copyright © 2008 Nuwan Niyadurupola and Nick Astbury. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT AND COMMENT Using intracameral cefuroxime as a prophylaxis for endophthalmitis

David Yorston Consultant Ophthalmologist, Tennent Institute of Ophthalmology, Gartnavel Hospital, 1053 Great Western Road, Glasgow G12 0YN, Scotland, UK.

Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW; ESCRS Endophthalmitis Study Group ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: preliminary report of principal results from a European multicenter study J Cataract Refract Surg 2006 Mar;32(3): 407–10

Purpose: To report results of the European Society of Cataract thalmitis are considered, the incidence rate observed in those & Refractive Surgeons (ESCRS) multicentre study of the treatment groups not receiving cefuroxime prophylaxis (23 cases prophylaxis of endophthalmitis after cataract surgery. in 6,862 patients) was almost five times as high (odds ratio [OR] Setting: Twenty-four ophthalmology units and eye clinics in 4.59; 95% confidence interval [CI] 1.74–12.08; p=0.002) as Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey, that in the groups receiving this treatment (5 cases in 6,836 and the United Kingdom, with an administrative office in Ireland, a patients). If only cases proved to be due to infection are coordinating centre in England, and a data management and considered, the rate was more than five times as high (OR 5.32; statistical unit in Scotland. 95% CI 1.55–18.26; p=0.008) in the treatment groups not Methods: This partially masked randomised placebo-controlled receiving cefuroxime. Although the use of perioperative multinational clinical study aimed to evaluate prospectively the levofloxacin eyedrops as prophylaxis was also associated with a prophylactic effect of an intracameral cefuroxime injection and/or reduction in the observed incidence rate of postoperative endoph- perioperative levofloxacin eyedrops on the incidence of endoph- thalmitis, this effect was smaller and was not statistically significant, thalmitis after phacoemulsification cataract surgery. The study whether total reported cases or only cases proven to be due to began in September 2003 and was terminated early in January infection were used in calculating the rates. As not all follow-up 2006. The study used random allocation of patients in a 2x2 procedures are complete, it is possible that further cases of factorial design. endophthalmitis may be reported; however, it is not expected that Results: By the end of 2005, complete follow-up records had this will alter the main conclusion. Nevertheless, it is anticipated been received for 13,698 study patients. Such a clear beneficial that successful completion of follow-up procedures in all patients effect from the use of intracameral cefuroxime had been observed will increase the total number in the study to approximately 16,000. that it was agreed it would be unethical to continue the study and Conclusion: Intracameral cefuroxime administered at the time of to wait for the completion of all follow-up procedures before surgery significantly reduced the risk for developing endoph- reporting this important result. If total reported cases of endoph- thalmitis after cataract surgery.

Comment Preparing a This paper presents the results of a large and any adverse effects.1 well-designed randomised trial, which It is possible that these results on the cefuroxime injection examined the effectiveness of an injection of prophylactic effect of intracameral cefuroxime cefuroxime 1 mg in the anterior chamber at might be different in developing countries. This You will need the following: the conclusion of cataract surgery. The results study was carried out in Europe, and it was also • Vial of 250 mg cefuroxime showed such a great benefit from the use of carried out on eyes that were having phaco- • 2x10 ml normal saline cefuroxime that the trial was stopped early, emulsification. It is likely that the majority of • 2 ml syringe because it was considered unethical not to these eyes had clear corneal incisions, with no • 1 ml syringe use the treatment. sutures. Few clinics in developing countries From these figures, out of 10,000 cataract routinely use phacoemulsification.They tend to Method operations without postoperative intracameral favour extracapsular extraction, a technique in 1 Dissolve the cefuroxime in cefuroxime, 23.3 would be expected to develop which the wound is covered with a conjunctival 12.5 ml of normal saline culture-positive endophthalmitis. With intrac- flap and which may be associated with a lower (20 mg/ml) ameral cefuroxime, this number would only be risk of infection. However, since the type of 2 Draw up 1 ml of the 4.4 (OR=5.32, 95%; CI 1.55–18.26). wound closure is not the only factor in the cefuroxime solution (20 mg) Globally, 10 million cataract operations are occurrance of endophthalmitis, similar prophy- in the 2 ml syringe performed every year. This gives an incidence lactic results may be obtained with the 3 Make up to 2 ml with 1 ml of endophthalmitis of 23,000 per year. If all intracameral injection of cefuroxime at the end normal saline (10 mg/ml) surgeons used intracameral cefuroxime in of extracapsular cataract extraction. 4 Draw up 0.1 ml of this every case, the incidence of endophthalmitis Despite these uncertainties, this study solution (1 mg) with the would be reduced to 4,400. represents the best evidence we have regarding 1 ml syringe and inject into the prevention of this devastating complication. What about toxicity? It appears that the the anterior chamber, intracameral injection of cefuroxime is not Reference using a Rycroft cannula, toxic: Swedish researchers have published 1 Montan PG, Wejde G, Setterquist H, Rylander M, through an anterior chamber Zetterström C. Prophylactic intracameral cefuroxime: paracentesis. results on many thousands of eyes that have evaluation of safety and kinetics in cataract surgery. received intracameral cefuroxime without J Cataract Refract Surg 2002;28(6): 982–987.

Copyright © 2008 David Yorston and P Barry et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. HIGH-RISK EYES Recognising ‘high-risk’ eyes before cataract surgery

Parikshit Gogate Mark Wood Head, Department of Paediatric Ophthalmology, Community Consultant Ophthalmologist, CCBRT Hospital, Eye Care, HV Desai Eye Hospital, Pune 411028, India. Box 23310, Dar es Salaam, Tanzania. Email: [email protected] Email: [email protected]

Certain eyes are at a higher risk of compli- Conjunctivitis should be treated with cation during cataract surgery. Operations topical antibiotics prior to intraocular on such ‘high-risk’ eyes are also more likely surgery. to yield a poor visual outcome (defined as Noble Bruce best corrected vision less than 6/60 after Potential visualisation surgery).1 Learning to recognise when eyes are at problems during surgery greater risk, and acting accordingly, will help Corneal opacity you to avoid complications. Even so, before Leucoma-grade opacity will make your task the operation takes place, it is good practice Conjunctivitis extremely difficult. You will find it difficult to to explain to such patients that a poor see details, in particular the capsulotomy. outcome is a possibility. This makes these There may be residual lens matter • Measuring intraocular pressure. It is patients’ expectations more realistic and remaining in the bag, which will be difficult important to measure intraocular pressure improves postoperative compliance and to see. It will also be challenging to place in all patients, for example to identify follow-up. In most cases, patients who are the intraocular lens (IOL) in the posterior glaucoma. blind with complicated cataract will be chamber with both haptics under the iris. • A fundus examination. The fundus can happy with even a modest improvement of be seen through all but the densest Patients suffering from trachoma with their vision. cataracts. You can do a B-scan if the pannus, corneal dystrophy, degeneration, It is also important to have available all medium is not clear. and band-shaped keratopathy, have hazy the equipment you may need to manage a corneas. Raised intraocular pressure may possible complication, for example a Your examination should be able to identify cause epithelial oedema. Phenylephrine vitrectomy machine in the case of capsular problems or signs which indicate that the dilating drops, if used too frequently, may rupture and vitreous loss. operation may not be straightforward. cause epithelial haze. Even minimal corneal Depending on where you are in the During the examination, you will need to handling during surgery may decrease world, certain ‘high-risk’ eyes will be more pay attention to the following areas, which corneal clarity. common: for example, pseudoexfoliation in are discussed in this article: Older patients, and those with Fuchs’ Somalia and India, onchocerciasis in • infection dystrophy, uveitis, or glaucoma, may have a Sudan, and angle-closure glaucoma in Asia. • potential visualisation problems compromised endothelium; their corneas You will get to know your local problems as • anatomy of the anterior segment may decompensate after surgery. The use of you perform more operations. • crystalline lens profiles high-viscosity viscoelastics, such as Healon • other health conditions. GV (sodium hyaluronate), and minimal Before you operate anterior chamber manipulations may help preserve the endothelium.2,3 It may be Get an accurate patient history. In particular, Infection advisable to perform extracapsular cataract obtain information on trauma, previous Any infection in or around the eye could lead extraction (ECCE), rather than phacoemulsi- operations, diabetes, dry eye, amblyopia, to endophthalmitis; infections should fication or manual small incision cataract and congenital abnormalities. If the patient therefore be treated before surgery. surgery (SICS).4 has only one eye, it is necessary to find out If there is a central corneal scar obscuring A blocked and infected lacrimal sac may what caused the loss of the other eye. the pupil, an optical sector iridectomy may cause endophthalmitis. It is extremely Perform a thorough eye examination. be helpful. This should include: important to check the sac patency before surgery. If the sac has mucoid regurgitation, A small pupil • Measuring best corrected visual instil local antibiotic drops and postpone A small, rigid pupil poses a problem in both acuity. This will determine whether a surgery. A dacryocystectomy (DCT) or dacryo- ECCE and SICS. Any unnecessary manipu- potentially risky operation should be cystorhinostomy (DCR) may be done if lation of the iris can result in a small pupil. attempted or avoided. If the patient only antibiotics do not resolve the condition This will make it difficult to see residual lens has one eye, is the patient content with before surgery is to take place. his or her present vision? Be aware that matter, the position of the IOL, and the you could make it worse. Entropion, ectropion, and lagoph- • A slit lamp examination with dilated thalmos: these eyes may have corneal pupil. Many potential problems become exposure before and after surgery. visible when the pupil is dilated. A slit lamp Eyelashes rubbing on the eye are a source examination will identify most problems of infection. In such eyes, the postoperative you are liable to face during surgery, such use of steroids may precipitate a corneal Hogeweg Margreet as subluxated lenses. Check the maturity ulcer. In addition, lack of a proper lid closure of the lens, the condition of the capsule, mechanism will not allow the eye drops and whether the cataract really is the instilled to stay in the conjunctival sac. cause of the patient’s poor vision, before These three conditions need to be corrected deciding to perform a potentially risky by surgery before you can contemplate a Small pupil operation. cataract extraction.

Copyright © 2008 Parikshit Gogate and Mark Wood. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. anterior capsule for capsulotomy. However, the nucleus can be very large and Traumatic cataracts can give nasty A small pupil can be dealt with in the the chamber deep. A deep anterior chamber surprises. The following steps may help you following ways: may be caused by a ‘reverse pupil block’. In deal with them: this situation, the iris should be raised from • Intracameral phenylephrine can be tried • Do an ultrasound B-scan before surgery. the capsule to even out the pressure; the first. • There may be corneal or iris tears that chamber depth will then return to normal.5 • A Sinskey hook or Y-shaped IOL dialler can need to be repaired. Make a small incision Viscoelastics help to maintain anterior be used to stretch the pupillary sphincter. at the 12 o’clock position and use air or chamber depth where necessary and to The instruments are placed 180° apart viscoelastic to form the anterior chamber ease the insertion of instruments. The entry and the pupil stretched right out to the before suturing the cornea. and exit of instruments should be kept to a limbus for ten seconds. • The anterior capsule may be broken or minimum. • If the pupil is still too small, a sphincter- torn. The tear can be extended as a CCC ectomy (three small radial cuts on the or an ‘envelope’ capsulotomy. sphincter pupillae, 120° apart) can be done Crystalline lens profiles • Keep the hydrodissection minimal, as there to facilitate nucleus delivery (Figure 1). The cataracts mentioned below will test a may be a posterior capsular tear. • Finally, iris hooks may be used to dilate surgeon’s skill, experience, and patience. In • If there is a posterior capsular tear, perform the pupil. ECCE, a capsular tension ring (CTR) can be dry aspiration under cover of viscoelastic. inserted after doing a continuous (complete) • Anterior vitrectomy is necessary if the If the surgeon is fastidious about having a circular capsulo rhexis (CCC) to stabilise the posterior capsule is torn. Try and preserve round pupil postoperatively, a small bag.6 Note that it is more important that the as much of the capsule as possible. peripheral iridectomy can be made and the CCC be ‘complete’ than it be ‘circular’, We normally do not put an IOL in at this cut extended to the pupillary margin (radial because an intact capsular margin ensures stage, but rather do this as a secondary iridotomy). The iridotomy can be sutured that the zonular tension is equally divided all procedure. later using 10-0 Prolene interrupted sutures around. Keep hydrodissection to a (Figure 2); this procedure demands consid- Membranous cataract occurs when the minimum. If you are using phacoemulsifi- erable skill and patience. However, this is lens matter has been absorbed and the cation, do it ‘in the bag’. If you are using not often required. anterior and posterior capsules fuse. ECCE or SICS, gently rotate the nucleus into A capsulotomy, possibly followed by an the anterior chamber (do not tumble) and Figure 1: Figure 2: Radial anterior vitrectomy, should clear the opacity. then deliver it outside the incision. All are Sphincterotomy for iridotomy Leave enough capsule to support an IOL. difficult procedures. It may be easier to a small, rigid pupil: sutured with This IOL will have to be placed in the sulcus. three cuts made 10.0 interrupted remove the lens (possible intracapsular 120° apart sutures extraction with vectis loop or lensectomy) and implant an anterior chamber lens. • Hard, dense nuclei are difficult to remove with phacoemulsification or SICS. You may prefer to do a routine extracap- sular extraction.4 • Hypermature cataracts have a small

nucleus and a wrinkled capsule. Anterior (http://drsobol.com) Sobol Aaron capsulotomy may be difficult. • Milky cataract (Morganian): when Uveitis Anatomy of the anterior making the capsulotomy, the ‘milk’ from the cataract fills the anterior chamber, Uveitis causes synechiae and cataract. segment obscuring the surgeon’s view. The anterior Posterior synechiae can be gently separated Narrow anterior chambers capsulotomy may not be complete. Filling using an iris repositor after instilling visco- These eyes make it difficult to perform the anterior chamber with viscoelastic elastic. This will probably mean that you will intraocular manipulations and to move the before starting the capsulotomy may help. perform a ‘can-opener’ capsulotomy. The instruments in and out of the eye. This • Fibrotic anterior capsule: these very sphincter pupillae may still need to be increases chances of iris injury and irido- thick, tough capsules may have to be cut stretched. Keep iris handling to a minimum dialysis at the iris root (the thinnest part of with scissors. in cases of uveitis, at it may trigger postoper- the iris) and at its major arterial circle. A narrow • Pseudoexfoliation causes weak zonules ative inflammation. It is advisable to start oral chamber occurs in hypermetropic eyes, while and glaucoma. There is an increased and local steroids a few days before surgery. deep anterior chambers occur in high myopes. chance of zonular dialysis. • A subluxated or dislocated lens can High ametropia occur in many conditions: very mature Other health conditions High hypermetropia or myopia create lenses, pseudoexfoliation, trauma, Glaucoma: specific problems. Marfan’s syndrome, and other • Eyes with long-standing glaucoma have The surgeon must re-check the A-scan syndromes. poor endothelial cell counts; postoperative and keratometer findings of IOL power, as corneal oedema may occur. errors are common in high myopia and high • Eyes that have been treated for many years hypermetropia. It is worth trying to do a with anti-glaucoma agents, like pilocarpine, refraction to help assess the A-scan readings. Noble Bruce may have pupils resistant to dilation. Very dense and mature cataracts can give • Complications like iris injury, capsular tear erroneous readings. When in doubt, it is and zonular dialysis can all aggravate better to veer on the side of slight myopia pre-existing glaucoma. postoperatively. Most patients prefer to see • Previous trabeculectomy means that the clearly in the medium-to-near distance functioning bleb must be preserved during Dislocated without spectacle correction. cataract surgery, by using either a corneal lens after Highly myopic patients have a wide incision (phacoemulsification) or a trauma angle, which facilitates instrument entry. Continues overleaf ➤

Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 13 HIGH-RISK EYES Continued HOW TO

temporal approach. To complicate matters, synechiae and a shallow anterior chamber are often present. Administering an eye anaesthetic: principles, techniques, and complications

HIV-positive patients: cataract surgery in these patients requires routine (and thus proper) care. However, such patients may Ahmed Fahmi Richard Bowman have posterior segment complications such Paediatric Ophthalmology Ophthalmologist, CCBRT Disability Hospital, as cytomegalovirus (CMV) retinitis, vasculitis, Fellow, CCBRT Disability Tanzania; Honorary Senior Lecturer, London and choroiditis, which may not be evident in Hospital, Tanzania. School of Hygiene and Tropical Medicine. a white cataract. Performing a B-scan may Email: [email protected] Email: [email protected] not always be helpful, but it should be done when fundus details are not clear. These Rationale patients are also prone to secondary infection. The trigeminal nerve carries the sensory innervation of the eye and adnexa in three divisions: ophthalmic, maxillary, and mandibular. The sensory fibres of the eye and Diabetes: it is important to try and keep adnexa are found in the ophthalmic division – with the exception of a portion of the the posterior capsule intact. Retinopathy sensory input from the lower lid, which is carried by the maxillary division. Blocking the progresses more rapidly in diabetic patients sensory fibres providesanaesthesia so that no pain is felt. after cataract surgery and a ruptured The motor supply of the extraocular muscles and levator palpebrae superioris is capsule can be a factor in rubeosis. Close carried by the oculomotor (III), trochlear (IV), and abducens (VI) nerves. Paralysing follow-up and timely laser treatment are these muscles by blocking their motor supply provides akinesia so that the eye does required. If possible, treat the retinopathy not move during surgery. preoperatively with laser. The motor supply of the orbicularis oculi, which is responsible for the gentle and forcible closure of the eye, is carried by the facial nerve (VII). Blocking these fibres will Onchocerciasis: this disease affects the provide better surgical exposure. It also reduces the risk of forcing out the ocular contents cornea, uvea, and retina. In endemic if the patient tries to close his eyelids forcibly after the surgeon opens the globe. areas, cataract surgery can be disappointing due to optic nerve and retinal pathology. You must take care when selecting patients Anatomy for cataract surgery, in order to avoid performing operations which will bring no It is important to recall the anatomy and to have a precise knowledge of the various benefit to patients. injection sites for the anaesthetic. The anteroposterior diameter of the globe averages 24.15 mm (range: 21.7 to 28.75 mm). The axial length of myopic eyes are at the Hypertension and high positive pressure upper end of this range. This increases the risk of globe perforation, especially with a during surgery: in general, it is important retrobulbar block. The length of the bony orbit is about 40 to 45 mm. On average, the to avoid a high positive pressure during surgery. anatomic equator is about 13 to 14 mm behind the limbus along the surface of the This can be caused by an inadequate or globe. At its closest distance to the bony orbit, the globe is about 4 mm from the excessive peribulbar block, or a tight bridle roof, 4.5 mm from the lateral wall, 6.5 mm from the medial wall, and 6.8 mm from suture. It is therefore important to control the floor. hypertension in patients. In addition, retrob- The retrobulbar space lies inside the extraocular muscle cone, behind the globe. ulbar haemorrhage should be identified early Relatively avascular areas of the orbit are confined to the anterior orbit in the lower and the operation postponed. Expulsive outer (inferotemporal) and upper outer (superotemporal) quadrants. The superonasal haemorrhage in one eye could alert you to quadrant is highly vascular and has limited space. possible problems in the second eye. Tenon’s capsule is the anterior extension of the visceral layer of dura investing the optic nerve. Therefore, the sub-Tenon’s space is continuous with the subdural space Asthma, chronic obstructive pulmonary and is, in effect, an anatomical pathway from the limbus to the retrobulbar space. disease and constipation: when in doubt Because the conjunctiva fuses with Tenon’s capsule 2 to 3 mm behind the limbus, the about whether to suture the wound, it is sub-Tenon’s space can be accessed easily through a scissor snip made there. always better to do so – especially in patients suffering from these conditions.

References Choosing the anaesthesia technique 1 Limburg H. Monitoring cataract surgical outcomes: methods and tools. Community Eye Health J 2002; Decide in advance what technique you are going to use. A retrobulbar block is more 15(44): 51–3. 2 Gogate PM, Kulkarni SR, Krishnaiah S, Deshpande RD, efficient in producing anaesthesia and akinesia and has a faster onset of action. Joshi SA, Palimkar A et al. Safety and efficacy of However, it carries a higher risk of rare, yet serious, complications, such as globe phacoemulsification compared with manual small perforation, retrobulbar haemorrhage, and injection of the anaesthetic into the incision cataract surgery by a randomised controlled clinical trial: six weeks results. Ophthalmology cerebrospinal fluid (CSF). Mastering the technique reduces these risks significantly. 2005;112: 869–874. The probability of complications is reduced in a peribulbar block; however, this 3 Basti S, Vasavada AR, Thomas R, Padmanabhan P. technique is slower and less efficient, it carries a higher risk of potential chemosis, Extracapsular cataract extraction: Surgical techniques. Indian Journal of Ophthalmology 1993;41: 195–210. and it puts more pressure on the eye. A retrobulbar block should be avoided if the axial 4 Bourne RR, Minassian DC, Dart JK et al. Effect of cataract length of the eye is greater than 27 mm. surgery on the corneal endothelium: modern phaco- emulsification compared with extra capsular cataract When a retrobulbar or peribulbar block is unsatisfactory, you can add a sub-Tenon’s surgery. Ophthalmology 2004;111(4): 679–85. block; it is a suitable supplement. By itself, the sub-Tenon’s block is useful for 5 Cionni RJ, Barros MG, Osher RH. Management of shorter procedures, provided you are operating on cooperative patients. The lens-iris diaphragm retropulsion syndrome during phacoemulsification. J Cataract & Refract Surg 2004; sub-Tenon’s block is more likely to be performed by an ophthalmic surgeon than 30: 953–956. by an ophthalmic anaesthetist. It enables top-up injections to be easily and safely 6 Ahmed IK, Cionni RJ, Kranemann C, Crandall AS. given. Sub-Tenon’s blocks are less likely to cause systemic complications than Optimal timing of capsular tension ring implantation: 1 Miyake-Apple video analysis. J Cataract & Refract Surg retrobulbar or peribulbar blocks. 2005;31: 1809–1813.

14 Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 Administering an eye anaesthetic: principles, techniques, and complications

The anaesthetic solution Components Lignocaine 2% is the most popular agent for nerve blocks. It has a rapid onset of action and its effect will usually last for an hour. Bupivacaine 0.5% lasts for three hours or even longer; this anaesthetic can be useful for prolonged procedures such as vitreoretinal surgery. Fahmi Ahmed and Bowman Richard Hyaluronidase may increase the effec- tiveness of a block by facilitating the spread of lignocaine or bupivacaine through the tissues. Hyaluronidase can be used in a concentration of approximately 50 units/ml (range: 25 to 75 ml). Adrenaline slows the absorption of anaes- thetic agents into the systemic circulation. This will provide a longer duration of action and reduce the risk of systemic toxic effects. It is used in a concentration of 1:100,000. Figure 1. Retrobulbar injection: the needle is passed through the junction of the middle and outer third of the inferior orbital rim, then straight back below the eye for Preparing the solution 15 mm. The needle should be parallel to the floor of the orbit and angled down. • To use hyaluronidase, add one ampoule (containing 1,500 units) to a 20 ml or by asking the patient to look in the four 23-gauge 24 mm needle (not 38 mm). 50 ml bottle of lignocaine 2% or cardinal positions of gaze. The needle should not have an acute bevel. bupivacaine 0.5% (this only stays active • Recall the possible complications (see • Feel the lower orbital rim and pass the for few days after mixing). box below), look out for their clinical needle through the skin or the conjunctiva at • To use adrenaline, add 0.1 ml from a vial manifestations, and be prepared to the junction of its lateral (outer) and middle of 1:1,000 adrenaline to 10 ml of the manage them. Anticipate complications thirds. The bevel of the needle should be anaesthetic solution (to get 1:100,000). in eyes with high axial length and in pointing upwards. The needle should be uncooperative patients. Staff should passed straight back below the eye for Note: Lignocaine often comes already attend resuscitation courses annually to 15 mm; it should be parallel to the floor premixed with 1:100,000 adrenaline. familiarise themselves with the handling of the orbit and angled down (Figure 1). of serious complications. You might feel the resistance as you Basic steps: all techniques pass through the orbital septum. • Change the direction of the needle so that • Introduce yourself to the patient. Explain Retrobulbar block the tip is pointing upwards and inwards the procedure in a short, simple, and • Prepare the injection: 2 to 3.5 ml of the understandable way and reassure the anaesthetic solution in a syringe with a sharp Continues overleaf ➤ patient. • Check the patient’s full name, the eye assigned for surgery, and the type of Complications of retro- or peribulbar anaesthesia surgery required. Retrobulbar haemorrhage is indicated by a hard and tense orbit with no retropulsion of • Record blood pressure, pulse rate, and the globe, proptosis, and subconjunctival haemorrhage. Management is usually conserv- respiratory rate as a baseline for the ative: surgery needs to be postponed. However, if the eye is very hard, you should monitoring of vital signs. These observa- perform an emergency lateral canthotomy to relieve pressure on the globe: clamp the tions should be repeated every two to lateral canthus with an artery forceps for 30 seconds, then cut it with sharp scissors. three minutes after the injection. Where available, pulse oximetry should be used Globe perforation is a rare and serious complication. Its adverse effects can be during injection and surgery. reduced if the anaesthetic is not injected because the complication has been recognised • Check that resuscitation equipment and in time. You should suspect a globe perforation if the eye becomes soft as you insert the medication is available to deal with a needle. If the globe has been engaged by the needle, it will not move as you ask the systemic complication, should one occur. patient to move his eye from side to side. Be very careful with your technique: advance • Lie the patient flat in a safe and the needle gently and take particular care in eyes with a high axial length (the needle comfortable way, with head supported. should be kept further away from the globe). • Ask the patient to look straight ahead (not upwards or nasally); hold the patient’s Systemic complications are very rare but very serious when they occur – they might be hand in front of his or her eye and ask him fatal. These complications occur if the local anaesthetic was injected into a blood vessel or her to look at it. or into the cerebrospinal fluid. The latter complication can be avoided by not advancing • Withdraw the plunger of the needle slightly the needle more than 24 mm from the entry site and by asking the patient to look before injecting the anaesthetic to make straight ahead (as proved by CT scan studies). Systemic complications manifest as circu- sure that you have not entered a blood latory collapse, disturbance in the level of consciousness (drowsiness), pulse vessel (blood) or the dural sheaths (CSF). irregularities, or convulsions. • Assess the efficiency of the anaesthesia

Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 15 HOW TO Continued Richard Bowman and Ahmed Fahmi Ahmed and Bowman Richard Fahmi Ahmed and Bowman Richard

Figure 2. Retrobulbar injection: the needle is advanced and the Figure 3. Peribulbar block: the needle is inserted through the antibiotic injected after the needle’s direction was changed so that fornix below the lateral limbus after the lower fornix was exposed the tip points upwards and inwards towards the opposite occipital (by pulling the lower lid down gently). eminence (slightly to the opposite side of the midline of the back of the skull). Note the drooping of the upper lid. Richard Bowman and Ahmed Fahmi Ahmed and Bowman Richard Fahmi Ahmed and Bowman Richard

Figure 4. Peribulbar block: the needle is advanced between the Figure 5. Sub-Tenon’s block: a pair of spring scissors is held caruncle and the medial canthus in a backwards and medial perpendicularly to make a small (0.5 mm) snip incision through direction, away from the globe. both the conjunctiva and Tenon’s capsule, 2 to 3 mm behind the limbus in the inferomedial quadrant.

towards the back of the skull. Feel the injected inferotemporally and between the • The inferotemporal anaesthetic injection resistance as the needle passes through caruncle and medial canthus. (4 to 5 ml in total) may be divided into the muscle cone. The needle should be three shots: 1 ml immediately posterior to advanced not more than 24 mm from the • Prepare the syringe: 7 to 10 ml of the the orbicularis oculi, 1 ml just anterior to skin in total (Figure 2). anaesthetic solution in the same syringe the equator, and 2 ml after the needle is • Inject slowly and look for dilation of the as for a retrobulbar block. advanced past the globe. pupil and drooping of the upper lid. • Expose the lower fornix by pulling the • The second injection (3 to 4 ml in total) can • Close the eyelids gently, cover with a pad, lower lid down gently (Figure 3). be given between the caruncle and the medial and immediately apply firm, gentle • Instil one drop of topical anaesthetic eye canthus, then passed back and slightly pressure for 5 to 10 minutes. This can be drops. medially (away from the globe) for about done manually or with a special balloon • Insert the needle through the fornix 24 mm, to inject 3 to 4 ml of the anaes- inflated to 30 mmHg. below the lateral limbus. Pass it thetic (Figure 4). Injecting directly through backwards and laterally for not more than the caruncle can cause significant bleeding. Note: A failed block can be repeated only once. 24 mm. Always keep it away from the • The superonasal approach is now

globe by directing it slightly downwards regarded as unduly dangerous and it Peribulbar (periconal) block (Figure 3). should be abandoned. This is due to high This block consists of two injections; it is • Inject at the level of the equator vascularity and limited space.

Copyright © 2008 Ahmed Fahmi and Richard Bowman. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. HOW TO

Sub-Tenon’s block • Prepare 2 to 3.5 ml of anaesthetic solution. Reducing the risk of infection: • Instil one drop of anaesthetic eye drops. A small swab soaked in topical amethocaine and left in the lower fornix for a minute is hand washing technique particularly effective. Sue Stevens • Cauterising the space before incision is Nurse Advisor to the Community Eye Health Journal, International Centre for extremely helpful in limiting both the risk Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, of subconjunctival haemorrhage and that London WC1E 7HT, UK. of an unintended extension of the incision. To do this, gently apply the bipolar cautery, barely touching but not pressing down on the conjunctival surface. This also helps to lift the Tenon’s

capsule away from the sclera. Niyadurupola Nuwan • Use a pair of spring scissors to make a small (0.5 mm long) snip through both the conjunctiva and Tenon’s capsule, 2 to 3 mm behind the limbus in the inferomedial quadrant of the globe. The scissors should not be opened more than halfway. It is essential to find the sub-Tenon’s plane, i.e. to dissect down to bare sclera. It helps Hand washing is a to hold the scissor blades so that their fundamental principle of plane is perpendicular to the ocular infection control surface instead of being parallel to it (Figure 5). Eyes are susceptible to infection by many • Use a specially designed blunt cannula to organisms, including gram-negative bacilli, inject the anaesthetic. However, if you do adenoviruses, the herpes simplex virus, and not have a specially designed cannula, a fungi. Infection puts eyes at higher risk of lacrimal cannula is a suitable alternative. complications after cataract surgery. Mount the cannula on a syringe Hand washing is the most important, funda- Rub palm to palm containing the anaesthetic solution. mental principle of infection control. It must be • Pass the cannula through the snip strongly encouraged and practised by all disci- incision. The incision should fit tightly plines in the health care setting. around the cannula. Hand washing is required in the following • Advance the cannula backwards with its situations: tip touching and following the curvature of the globe all the way to the retrobulbar • before any aseptic procedure Rub back of left hand over right palm space. As the equator is passed, the hand • before and after handling any patient and vice versa and syringe need to rotate away from the • after handling any soiled item globe so that the cannula tip stays in the • before and after handling food space (Figure 6). • whenever hands are, or even feel, soiled • Inject the anaesthetic carefully. • when entering and leaving a clinical area • after using the toilet or assisting a patient in Reference 1 Eke T, Thompson JR. Serious complications of local the toilet anaesthesia for cataract surgery: a 1-year national Rub palm to palm with fingers survey in the United Kingdom. Br J Ophthalmol 2007; Many health care workers are unaware of the interlaced 91(4): 470–5. need for frequent hand washing and that a certain technique is required for hand washing to Figure 6. Sub-Tenon’s block: the hand and be effective. syringe is rotated away from the globe as Written instructions for hand washing, as the equator is passed so that the cannula given below, should be displayed in all clinical tip stays in the space. areas. Rub backs of fingers on opposing • Wet hands with clean, preferably running, water palms with fingers interlocked • Apply soap or cleanser • Rub palm to palm • Rub back of left hand over right palm • Rub back of right hand over left palm • Rub palm to palm with fingers interlaced • Rub backs of fingers on opposing palms Rub around right thumb with left with fingers interlocked palm and vice versa Richard Bowman and Ahmed Fahmi Ahmed and Bowman Richard • Rub around right thumb with left palm • Rub around left thumb with right palm • Rub palm of left hand with fingers of right hand • Rub palm of right hand with fingers of left hand • Rinse off soap with clean, preferably Rub palm of left hand with fingers of running, water, and dry well. right hand and vice versa Copyright © 2008 Sue Stevens. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. REPORT Meeting the needs of children with congenital and developmental cataract in Africa

Paul Courtright and Childhood remains either patchy or non-existent.7 and monitoring purposes, a childhood Cataract Experts Meeting Group Although they are still few in number, cataract surgical rate should be calculated Kilimanjaro Centre for Community tertiary facilities for paediatric ophthal- for each VISION 2020 district (population: Ophthalmology PO Box 2254, Moshi, mology in Africa have strengthened the one to two million). The childhood cataract Tanzania quality of their surgical services over the surgical rate states how many cataract In much of Africa, childhood cataract is past three to five years. Unfortunately, operations should be performed in each becoming one of the leading causes of new better surgical services have not usually district per year in order to eliminate the cases of blindness reported per year.1 been matched by improvement in the other condition among the children residing in the Although there is insufficient data on services needed to strengthen overall district. childhood cataract, both congenital and management of congenital and develop- This information should be used to developmental, the backlog of children in mental cataract. These include better identify districts where the actual number need of surgery is estimated to be around programmes promoting early identification of cataract operations performed is too low 100 children per million population. The and referral, adequate follow-up, provision and to monitor annual progress towards number of new cases of corneal blindness is of spectacles, low vision care, or referral to reducing childhood blindness due to cataract. estimated to be around 20 children per inclusive education. million population per year.2,3 In May 2007, the Kilimanjaro Centre for Identifying and referring children The World Health Organization (WHO) Community Ophthalmology (KCCO), with with cataract recommends that there be one paediatric financial support from Dark & Light Blind Evidence suggests that the use of key ophthalmology tertiary centre per 10 million Care, brought together 18 people from informants (at the community level) may population4; however, few countries in Africa throughout Africa, as well as key personnel increase identification and referral of have reached this target. Even in settings from Europe and Asia, to draft recommen- children requiring surgery, particularly when with tertiary centres, few children are dations and to prepare a practical manual of local cultures are relatively cohesive and best practice for the management of when people living in the geographic brought in for surgery; of those who are, 8,9 most are brought in too late for surgeons to childhood cataract in Africa. This manual will area know each other. Additional research be able to achieve outcomes of the highest be available by August 2008. Materials from is needed to test this method for sustaina- bility and to test it in other settings. It should quality.5 This can be explained by the fact the workshop are available on the KCCO website: www.kcco.net also be compared with other approaches, that both communities and health care such as the use of health workers (for providers are not sufficiently aware that example, those doing immunisations). children can develop cataract. The lack of Recommendations In many countries, children with cataract programmes to identify and refer children Efforts needed at the national level in are still admitted to schools for the blind. with cataract compounds this problem. It Africa to address childhood cataract National policies on admission of children to also needs to be noted that, in most Throughout Africa, national prevention of schools for the blind (in particular, ophthal- hospitals or other surgical facilities, boys blindness or VISION 2020 committees mological examination prior to admission) outnumber girls; this is primarily due to need to identify existing tertiary centres for are either absent or not enforced. All those cultural constraints and does not reflect any paediatric ophthalmology. In collaboration engaged in eye care, education, and recognised biological risk factors associated with these centres, they need to define rehabilitation of children need to collaborate with males.5,6 each centre’s respective catchment area to first provide children with the best Virtually all children receiving surgery for (population: 10 million). For each catch- possible eye care before placing them in congenital cataract in Africa will require long ment area, existing data on childhood appropriate educational settings. term follow-up for refractive error correction cataract should be compiled (including age, The exact timing of cataract surgery and low vision care. However, follow-up sex, and place of residence). For planning depends upon the individual characteristics of each child. However, when a child’s pupil is white, health care staff must treat this as K Hennig K an emergency and ensure that the child is seen by an ophthalmologist as soon as possible. To ensure this, the curricula for training mid-level and primary level health providers should be reviewed and upgraded, if necessary. It would also be helpful to improve the knowledge and skills of existing care providers.

Financing cataract surgery in children For a paediatric ophthalmology tertiary centre, the cost of equipment, consumables (e.g. high-power intraocular lenses and spectacle frames for babies and small children), and recurrent expenses are very A child prepared for high and require adequate funding. In most cataract surgery. NEPAL cases where programmes have achieved a significant increase in the number of opera-

Copyright © 2008 Paul Courtright and Childhood Cataract Experts Meeting Group. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. as possible, in particular because refractive error changes periodically in children. A girl with bilateral Relevant personnel in districts served by cataract. TANZANIA the tertiary centre should be trained to Elizabeth Kishiki Elizabeth provide basic follow-up services. It will be challenging to link tertiary and district services to ensure that children are kept track of. To ensure good practice, it is essential to establish systems of accountability.

Linking eye care, low vision, education, and rehabilitation services Successful low vision service provision requires strong links between eye care and low vision services, as well as accurate refraction and near vision assessment. In addition, low vision services should have links with education and rehabilitation services. In most settings, special education teachers and rehabilitation workers need additional training. Eye care providers need to take the lead in initiating and maintaining low vision and educational support of children. tions in children, it has been necessary to activities for early detection, training health References waive surgical fees and to reimburse much staff, and implementing a tracking system 1 Waddell KM. Childhood blindness and low vision in of the travel expenses incurred by families to ensure that children are brought back for Uganda. Eye 1998;12: 184–92 2 Foster A, Gilbert C, Rahi J. Epidemiology of cataract in bringing children for surgery and follow-up. follow-up, spectacles, and low vision care. childhood: a global perspective. J Cataract Refract Surg These approaches may need to be Every tertiary centre should have facilities to 1997;23: 601–4. considered in most settings in Africa and will provide low vision services and spectacles 3 Gilbert C, Raji JS, Quinn GE. Visual impairment and blindness in children. In: Johnson GJ, Minassian DC, require dedicated financial support. for children. Weale RA et al, eds. Epidemiology of eye disease. Follow-up after surgery is essential London: Arnold Publishers, 2003. Surgical intervention and surgical throughout childhood. All centres providing 4 WHO. Preventing blindness in children: Report of a WHO/IAPB Scientific Meeting. WHO/PBL/00.77 facilities surgery should adopt strategies that have 2000. All children (in particular, younger children) been shown to be effective in promoting 5 Mwende J, Bronsard A, Mosha M, Bowman R, Geneau should only be operated on by paediatric regular follow-up; these strategies include R, Courtright P. Delay in presentation to hospital for surgery for congenital and developmental cataract in ophthalmologists in well-equipped tertiary counselling, keeping good records, using cell Tanzania. Br J Ophthalmol 2005;89: 1478–82. centres; these centres need to ensure that phones (mobile phones) to keep in touch, 6 Yorston D, Wood M, Foster A. Results of cataract high-quality paediatric anaesthetic services reimbursing transport costs, and organising surgery in young children in east Africa. Br J Ophthalmmol 2001;85: 267–71. are available. A paediatric ophthalmology family visits by local eye care workers. 7 Muhit MA. Childhood cataract: Home to hospital. tertiary centre should have a ‘childhood Comm Eye Health J 2004;17: 19–22. blindness coordinator’ on the staff. This Decentralisation of follow-up services 8 Muhit MA, Shah SP, Gilbert CE, Hartley SD, Foster A. The key informant method: a novel means of ascer- person will be responsible for counselling Low vision services and some refractive taining blind children in Bangladesh. Br J Ophthalmol parents (and older children), organising services should be decentralised as much 2007;91: 995–9.

MSc Community Eye Health

The London School of Hygiene & Tropical Medicine is Britain’s national school of public health and a leading postgraduate institution in Europe for public health and tropical medicine. It is a part of the University of London. We are pleased to call for applications for the internationally renowned MSc in Community Eye Health, commencing September 2008. This course aims to equip eye health professionals with the knowledge and skills to reduce blindness and visual disability by developing a community-oriented approach to eye health in line with the aims and objectives of VISION 2020: The Right to Sight. Applicants should have a degree in ophthalmology or a related field. Students are expected to be health care professionals involved in eye care, or to have an appropriate technical qualification and relevant work experience. For 2008/9 academic year, eight scholarships funded by the Department for International Development have been awarded to the School. Funding covers full tuition fees and airfares. If your organisation can fund the living allowance and if you live in a low- or middle-income commonwealth country, you might be eligible to apply for an award. Please contact Adrienne on [email protected] for more information. To request a prospectus and application forms, contact: The Registry, 50 Bedford Square, London WC1B 3DP, UK E-mail: [email protected] Tel: +44 (0)20 7299 4646 Fax: +44 (0)20 7323 0638 Website: www.Lshtm.ac.uk/courses Please quote Ref: AJCEH

Community Eye Health Journal | Vol 21 ISSUE 65 | MARCH 2008 19 Useful resources for cataract complications Community Eye Health Sandford-Smith J. Eye surgery in hot and disinfection. Poster. climates. 2nd ed. UK £9 (plus postage and Both available from the International Centre Journal back issues packing). Available from the International of Eye Health. Free of charge to low- and Sandford-Smith J. Sutureless cataract Centre for Eye Health. middle-income countries, UK £3 otherwise. surgery: principles and steps. Comm Eye Health J 2003;16(48): 51–53. Other resources Suppliers’ addresses Hennig a and Schroeder B. Sutureless CBm: Email [email protected] Schroeder B. Sutureless cataract cataract surgery: ‘fi shhook technique’ or write to CBM Procurement, Christian extraction: complications, management instruction course. CD-ROM. Available Blind Mission e.V., Nibelungenstrasse 124, and learning curves. Comm Eye Health J free of charge from CBM. 64625 Bensheim, Germany. 2003;16(48): 58–59. Sandford-Smith J. Extracapsular cataract Waterstones: 71–74 North Street, extraction with iol implantation for Brighton, East Sussex BN1 1ZA, UK. Email: Books developing countries. Video. [email protected] noble Ba and Simmons iG. Complications UK £5 (incl. post and packing). Available international Centre for Eye Health: of cataract surgery: a manual. 2nd ed. from the International Centre for Eye Health. Write to Jenni Sandford, London School of Butterworth Heinemann, 2001. Available Stevens S. Control of infection in Hygiene and Tropical Medicine, Keppel from Waterstones. UK £54.99 plus post ophthalmic practice. Poster. Street, London WC1E 7HT, UK. and packing. Cox i and Stevens S. Sterilisation Email: [email protected] neWs AnD nOTICes Meetings participants with the goals and objectives rehabilitation workers, special educators of VISION 2020: The Right to Sight and and other professionals with relevant World ophthalmology Congress, 28 the principles involved in establishing experience. Fee: US $1,400. Scholarships June–2 July, 2008, Hong Kong. For more community eye health programmes at are available. more information: Visit information, visit www.woc2008hongkong. regional or national level. target www.gju.edu.jo/ProfProg/ org or write to Angela Cho, Department of audience: Ophthalmologists and eye Visionrehabilitation/index.html or write Ophthalmology & Visual Sciences, The health charity programme managers. to Nathalie Bussieres, German Jordanian Chinese University of Hong Kong, 3/F, Hong Fee: UK £700. more information: University, PO Box 35247 Amman, Kong Eye Hospital, 147K Argyle Street, Visit www.lshtm.ac.uk/prospectus/ 11180 Jordan. Kowloon, Hong Kong. short/spv.html. For applications, email iaPB General assembly, 25–28 August, [email protected] or write to Subscriptions 2008. Venue: Hotel Panamericano, Buenos Registry, 50 Bedford Square, London Change of address: it is important to us Aires, Argentina. theme: Excellence and WC1E 7HT, UK. that you continue to receive your copy of the Equity in Eye Care. Registrations and hotel Professional diploma in vision rehabili- journal even if you move to another address reservations are in progress. For more infor- tation, German Jordanian University, or another country. If you have recently moved, mation and to book, please visit http://8ga. Jordan. Date: October 2008 to April 2009. or if you are planning to move, please send iapb.org or email [email protected] aim: Prepare professionals to plan and your name and postal address to Anita assess interventions for children with visual Shah, International Centre for Eye Health, Training disability in all areas of development, using London School of Hygiene and Tropical Planning for ViSion 2020, London, UK. a transdisciplinary approach. language: Medicine, Keppel Street, London, WC1E Date: July 2008. objectives: to familiarise English target audience: optometrists, 7HT, UK. Email: [email protected] Community Eye Health Next issue Supported by:

Journal Wilson Daisy

Christian Blind Mission The late (CBM) sightsavers Dr hans hirsch International

The next issue of the Community Eye Health Journal will be on the theme eye care for older persons

20 Community EyE HEaltH Journal | Vol 21 iSSuE 65 | marCH 2008