fection In an ar d l u In c Kapoor, J Ocul Infect Inflamm 2018,2:1 f l O a

f m

o

m Journal of Ocular Infection

l

a a

t n

i

r o

u n o

J and Inflammation ResearchResearch Article Article OpenOpen Access Access Retrospective Analysis of Combined and Correction in Adult Population Smita Kapoor*, Prabu VR, Udayakumar S and Dukale S Department of Pediatric and Strabismus, Sankara Hospital, Coimbatore, India

Abstract Purpose: To study the effectiveness of combined cataract and strabismus correction in adults. Methods: A retrospective study involving 100 patients who underwent cataract extraction combined with strabismus correction was done. The patients were divided into 2 groups based on measurement of angle of strabismus. Group 1 included cases measuring <60 Prism Diopter and Group 2>60 Prism Diopter. Results: The results were analyzed based on motor alignment and visual outcome. Good motor alignment (<10 PD) was achieved in 60.7% of patients in group 1 while none of the patients had a good motor alignment of <10 PD in group 2. Patients in group 2 underwent a second combined surgery of the other eye after a period of 6 months to attain a satisfactory alignment. However, the second eye was not included in the study. Visual success of BCVA>20/40 was achieved in 91% of patients. There was no statistical difference in BCVA between the two groups. No serious complications were seen post-operatively. Conclusion: Strabismus correction in adults is very effective as it is more than a cosmetic correction. It not only adds to patient satisfaction but also improves their quality of life. Thus, if cataract and strabismus coexist, they can be corrected in a single sitting in selected cases without any significant complications.

Keywords: Cataract; Strabismus; ; Vision finally 100 patients were made a part of the study. All patients underwent a thorough anterior and posterior segment examination. Introduction The eye with lesser was selected for surgery. The angle of deviation was measured by alternate prism and using loose The co-existence of cataract and strabismus has been reported in literature. However, a consensus as to whether cataract surgery should prisms. Sensory evaluation was done only in cases that had good vision precede strabismus correction, or both should be done in a single using Worth Four Dot test. A written informed consent was taken sitting has not been reached [1]. Though combined squint and cataract from all the patients prior to surgery. All cases were performed by a surgeries have been performed [1-3], a large series of patients has not single surgeon trained to do both cataract and squint surgeries under been studied so far. It was earlier thought that strabismus correction in peribulbar anesthesia. First squint correction was performed, and all adults is a mere cosmetic correction which does not hold true anymore. patients underwent recession and/or resection procedures via a limbal Even in cases with long standing squint there is post-operative conjunctival incision. Muscles were sutured using 6-0 polyglactin 910 improvement in binocular function [4,5]. The binocular field of vision and via 8-0 polyglactin 910. This was followed by small improves, and some may even develop . Previous studies have incision cataract surgery using a temporal 5.5 mm incision. A temporal suggested that patients with long standing strabismus may develop incision was chosen as it is more astigmatically neutral as compared to post-operative binocular single vision and stereopsis to some extent [6- a superior incision. Post-operatively oral antibiotics, topical antibiotic- 8]. We know for a fact that enables us to extract subtle steroid combination and lubricants were applied. Post-operative visual details which are not available to one eye alone. For the to function acuity, intraocular pressure, anterior and posterior segment evaluation in their full capacity, it is required for them to be aligned appropriately. was done. Best corrected visual acuity and alternate prism and cover Thus, correction of strabismus at any age is done to restore the eye to test were recorded at 1st day, 1 month and 6 months to assess the motor normal position for them to function normally. In patients above the alignment and visual outcome. The results were analyzed at the end of age of 50, cataract is the main cause of defective vision and if combined 6 months. with squint correction will be beneficial for the patient. This reduces the number of surgical procedures and optimizes visual acuity, fusion Inclusion criterion and binocular single vision in a single setting. Cataract and strabismus Patients with alternating squint since childhood measuring more surgeries both carry risk of complications, and when done together it is presumed that the frequency will be more. Complications related to include dellen, inclusion cyst, scleral perforation, anterior segment ischemia, slipped muscle, lost muscle, and fast *Corresponding author: Smita Kapoor, Department of adherence syndrome and lid retraction [9]. Following cataract surgery and Strabismus, Sankara Eye Hospital, Coimbatore, India, Tel: 0422 425 6789, E-mail: [email protected] posterior capsule rupture, , , suprachoroidal hemorrhage, cystoid , posterior capsule Received: December 07, 2017; Accepted: January 18, 2018; Published: January opacification can occur [10]. This study reports the risks and benefits of 25, 2018 doing combined surgery in adults. Citation: Kapoor S, Prabu VR, Udayakumar S, Dukale S (2018) Retrospective Analysis of Combined Cataract and Strabismus Correction in Adult Population. J Ocul Materials and Methods Infect Inflamm 2: 102. Case records of 150 patients who underwent combined cataract Copyright: © 2018 Kapoor S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted and squint procedures from January 2014 to June 2016 were reviewed. use, distribution, and reproduction in any medium, provided the original author and Patients who did not fulfil the inclusion criteria were excluded and source are credited.

J Ocul Infect Inflamm, an open access journal Volume 2 • Issue 1 • 1000102 Citation: Kapoor S, Prabu VR, Udayakumar S, Dukale S (2018) Retrospective Analysis of Combined Cataract and Strabismus Correction in Adult Population. J Ocul Infect Inflamm 2: 102.

Page 2 of 3 than 20 PD and <80 PD were included in the study. Patients with Preoperative Postoperative PBCT immature senile cataract and well dilating were selected. PBCT <10 <11-20 <21-30 <31-40 10-20 7 0 0 0 Exclusion criterion 21-30 4 2 0 0 Patients with mature, hyper mature, hard, traumatic and sub 31-40 20 0 0 0 luxated were excluded. Cases that had any , 41-50 15 15 1 0 retinal/macular pathology or that would affect post-operative 51-60 5 14 1 0 visual acuity were also excluded. Patients with pseudo exfoliation, small 61-70 0 8 4 1 pupils and deep sockets that could cause intraoperative complications 71-80 0 0 0 3 were not made a part of the study. Restrictive, paralytic and vertical Table 5: Association between preoperative and post-operative PBCT. squints presenting with or abnormal head posture were not included. Also, high myopes (Axial length >26.5 mm) were excluded PBCT Pre-op Post-op P-value as there would be an increased risk to scleral perforation in such cases. <60PD 64 100 <0.0001 Statistical analysis >60PD 36 0 <0.0001 Table 6: Pre-operative and postoperative angle of deviation measurement. Data was analyzed descriptively first. Paired sample t-test was used to compare the mean difference pre-operative versus post-operatively. Mean ± SD (n = 100) Parameters P-value Best corrected visual acuity and alternate prism and cover test data were Pre-operative Post-operative analyzed using paired sampled t-test. A two-sided p value of <0.05 was Visual acuity 1.08 ± 0.18 0.24 ± 0.12 <0.0001 statistically significant. All analysis was done by using the SPSS (SPSS, PBCT 48.72 ± 13.55 9.98 ± 9.54 <0.0001 Chicora, IL) software for Windows. Table 7: Comparison of the pre-operative and post-operative BCVA and prism bar Results cover test. The mean age was 57.6 ± 9.3 years and age ranged from 30 years to 76% of the patients had vision <20/200 pre-operatively while 99% 78 years. In group 1 the age range was 56.9 ± 9.1 years and in group 2 of the patients had vision >20/200 post-operatively. Out of this 46% it was 56.7 ± 10.1 years. There was no statistical difference between the had best corrected visual acuity (BCVA) >20/32 and 91% >20/40. groups (p>0.5) in terms of age. Majority of the patients presented with Table 3 shows the comparison between the pre-operative and post- alternating (95% n=95). Only five patients had alternating operative best corrected visual acuity. The only patient with BCVA . The comparison of gender and operated eye is given in Tables <20/200 developed posterior capsule opacification which was treated 1 and 2 respectively. Though there were more females in the study, no with NdYAG laser capsulotomy and the patient subsequently showed gender predilection has been reported in the community. This could be improvement in vision. a selection bias by the authors. In cases where the angle of deviation was between 20 to 25 prism Gender No. of patients Percentage diopter (PD) only one muscle was operated. 10 patients with exotropia Female 62 62 <25 PD underwent lateral rectus recession only. 90 patients had angle Male 38 38 of deviation >25 PD and underwent unilateral recession-resection Total 100 100 procedure (Table 4). Table 1: Gender distribution among the patients. The comparison between angle of deviation pre-operatively and Operated Eye No. of patients Percentage post-operatively showed significant improvement in all the groups Right Eye (OD) 49 49 (p<0.0001). 51% of the cases had prism bar cover test (PBCT) <10 PD. Left Eye (OS) 51 51 Pre-operatively 36% of the patients had >60 PD of deviation which Total 100 100 reduced to <40 PD in all the patients post-operatively. However, all the Table 2: Operated eye of the patients. patients required a second surgery to achieve good motor alignment (<10 PD) (Table 5). Preoperative BCVA Postoperative BCVA BCVA category P value N (%) N (%) Comparison of the pre-operative and post-operative BCVA and 20/20-20/32 0 (0%) 46 (46%) <0.0001 prism bar cover test showed significant improvement which was 20/40-20/60 2 (2%) 52 (52%) <0.0001 statistically significant (p<0.0001). 20/80-20/125 12 (12%) 1 (1%) <0.0001 20/200 10 (10%) 0 (0%) <0.0001 Pre-operative BCVA in Group 1 was 47.77 ± 12.9 and in Group 2 <20/200 76 (76%) 1 (1%) <0.0001 was 47.98 ± 12.44. Post-operative BCVA in Group 1 was 9.76 ± 8.9 and Total 100 (100%) 100 (100%) in Group 2 was 9.75 ± 9.34. There was significant improvement in visual acuity post-operatively in both the groups but there was no statistical Table 3: Comparison of pre-operative visual acuity to postoperative visual acuity in patients. difference between Group 1 and 2 (p>0.4) (Tables 6 and 7). There were no significant complications at the end of 6 months in Muscles operated No. of patients 1 10 any of the patients. On the first post-operative day there was chemosis, 2 90 lid edema, corneal edema and anterior segment inflammation which Total 100 resolved subsequently at the end of 1 week. Grave complications like anterior segment ischemia and endophthalmitis were not seen in any Table 4: Total number of patients who underwent recession alone or recession- resection procedures. of the patients.

J Ocul Infect Inflamm, an open access journal Volume 2 • Issue 1 • 1000102 Citation: Kapoor S, Prabu VR, Udayakumar S, Dukale S (2018) Retrospective Analysis of Combined Cataract and Strabismus Correction in Adult Population. J Ocul Infect Inflamm 2: 102.

Page 3 of 3

Discussion and visual acuity (Figures 1-4). None of the patients had binocular interaction in the past as they had squint since childhood; however The results clearly show that this procedure is safe and gives good post-op motor alignment was good. Contrary to the study conducted results in both the defined outcomes i.e., motor alignment and visual by Sujata Guha, MD, Sankara Nethralaya, Vision Research Foundation, success in one sitting. Thus the patient does not have to undergo two Chennai, India [2] which suggested that patients with long standing subsequent surgeries. strabismus developed poor motor alignment post-operatively, our study The results of our study show that 91% patients showed improvement has shown good post-op results. The reason for this could be that all our in best corrected visual acuity (>20/40) and 98% had BCVA>20/60. patients have alternating squint and no predominant eye which could 51% showed significant improvement in motor alignment (<10PD). have been a reason of poor alignment in their study. Since we operated Patients with pre-operative PBCT>60 PD required a second surgery to patients with large angles of squint it was not necessary to do cataract obtain improved motor alignment. Even though all the patients in the surgery before squint correction. Literature search of combined study developed squint before cataract, the visual outcome and motor and strabismus surgery revealed that a number of reports have been alignment was good. Thus, it suggests that cases that have alternating published. However a large case series has not been reported. squint with equal dominance develop good post-operative alignment Conclusion It was seen that most of the patients did not know that their squint could be corrected. After proper counselling, patients agreed for combined surgery and were satisfied post-operatively. This study has proved that educating people about correction of strabismus along with cataract extraction gives them not only improvement in vision but also reduction in angle of squint. None of the patients had binocular function pre-operatively as suggested by Worth Four Dot Test. Post- operative sensory evaluation was not evaluated which was a limitation. Figure 1: Pre-operative photograph showing (OD) exotropia with senile In cases with good pre-operative vision, sensory evaluation could be immature cataract. done henceforth. It was also presumed that the rate in a combined surgery would be more. However, none of the patients in our study had intraoperative or post-operative complications. Only one patient developed posterior capsule opacification at the end of 6 months. Thus, in the hands of an experienced surgeon combined squint and cataract surgery gives good results. The small sample size is a limitation of the study. Further studies need to be conducted to validate our results. References 1. Ticho BH, Ticho KE, Kaufman LM (2006) Combined strabismus and lens Figure 2: Post-operative photograph showing orthotropia and (OD) pseudophakia. surgery. J AAPOS 10: 430-434.

2. Guha S, Ravishankar K, Surendran TS (2008) Performing combined strabismus and cataract surgery: An effective approach in selected cases. Strabismus 16: 5-9.

3. Squirrell D, Edwards M, Burke J (2001) Combined strabismus and phacoemulsification cataract surgery: a useful option in selected patients. Eye (Lond) 15: 736-738.

4. Kushner BJ (2011) The efficacy of strabismus surgery in adults: A review for primary care physicians. Postgrad Med J 87: 269-273.

5. Baker JD (2002) The value of adult strabismus correction to the patient. J AAPOS 6: 136-140.

Figure 3: Pre-operative photograph showing (OD) exotropia with senile immature 6. Currie ZI, Shipman T, Burke JP (2003) Surgical correction of large-angle cataract. exotropia in adults. Eye (Lond) 17: 334-339.

7. Edelman PM (2010) Functional benefits of adult strabismus surgery Am Orthopt J 60: 43-47.

8. Gopal KSS (2010) Gains beyond cosmesis: Recovery of fusion and stereopsis in adults with longstanding strabismus following successful surgical realignment. Indian J Ophthalmol 58: 171.

9. Olitsky SE, Coats DK (2015) Complications of strabismus surgery. Middle East Afr J Ophthalmol 22: 271-278.

10. Stein JD (2012) Serious adverse events after cataract surgery. Curr Opin Ophthalmol 23: 219-225. Figure 4: Post-operative photograph showing orthotropia and (OD) pseudophakia.

J Ocul Infect Inflamm, an open access journal Volume 2 • Issue 1 • 1000102