Year : 2014 | Volume
: 6 | Issue : 2 | Page : 54--56
Causes of poor visual outcome of extracapsular cataract extraction with posterior chamber intraocular lens implantation
Khalil Ali Ibraheim1, Kamal Hashim2, Mustafa Alsaraj3,
1 Assistant Professor, Kordofan University, Elobied, Khartoum State, Sudan
2 Associate Professor, Alnileen University, Khartoum State, Sudan
3 Professor Sudan Medical Specialization Board, Khartoum State, Khartoum, Sudan
Khalil Ali Ibraheim
Kordofan University, Faculty of Medicine, Elobied
Aims: To detect the causes of poor visual outcome among patients who had extracapsular cataract extraction and intraocular lens (IOL) implantation. Materials and Methods: All patients who had ECCE and IOL implantation 6 weeks or more following surgery and who come for regular follow-up were picked from the Statistical Department and assessed for visual acuity, and for those with poor vision uncorrectable with glasses or any other mean of correction, complete ophthalmic examination including pupillary reactions measurement of intraocular presser (IOP) and direct and indirect ophthalmoscopy was performed. Results: Most of the patients were elderly (74%) and females were slightly more than males. The predominant type of cataract was senile cataract, 89% of patients complained of poor vision, 35% with visual acuity after operation less than 6/60 represent the biggest group with poor vision. Concerning intraocular pressure, the majority of pseudophakic eyes had normal range of IOP (75%), while 25% of the study group had raised intraocular pressure, although some of the patients with normal tension showed signs of advanced glaucomatous optic neuropathy. The most common causes of poor vision in the anterior segment were: Posterior capsule opacification (24%), corneal edema, opacity, pannus and bullous keratopathy (23%), amblyopia (6%), IOL decentration (5%), squint (4%), intraocular scarring (3%), nystagmus (2%), shrunken eyes (2%) and epithelial down-growth (1%). The most common causes of low vision in the media and posterior segment were glaucomatous optic neuropathy (28%), vitreous opacities (23%), macular edema (19%) and optic atrophy non-glaucomatous (19%), age-related macular degeneration (11%), toxoplasmic choroidoretinitis (6%), retinal detachment (6%), vitro-retinal bands (2%) and organized macular hemorrhage (1%); in some eyes, more than one cause was detected. Conclusion: The most common contributory factors for poor vision were incomplete ophthalmic examination before surgery, poor case selection and incomplete and irregular follow-up besides the above-mentioned causes.
|How to cite this article:|
Ibraheim KA, Hashim K, Alsaraj M. Causes of poor visual outcome of extracapsular cataract extraction with posterior chamber intraocular lens implantation.Sudanese J Ophthalmol 2014;6:54-56
|How to cite this URL:|
Ibraheim KA, Hashim K, Alsaraj M. Causes of poor visual outcome of extracapsular cataract extraction with posterior chamber intraocular lens implantation. Sudanese J Ophthalmol [serial online] 2014 [cited 2021 May 10 ];6:54-56
Available from: https://www.sjopthal.net/text.asp?2014/6/2/54/150995
Cataract surgery is one of the most important techniques for relieving and prevention of blindness. Also, it is one of the safest and successful procedures in the large majority of cases, but complications may occur at any stage of the operation and the result may not reach the patient expectation. Poor visual outcome is an area of research in order to pick up and analyze its causes and put recommendations that may help the policy makers to set certain strategies that help in improving the outcome of cataract surgery. Modern microsurgical techniques allow intervention for cataract before it has resulted in blindness; normal vision typically is restored with intraocular lens implantation.  Delay in treatment does not, except in certain very uncommon situations, result in an adverse outcome.
The method (now becoming obsolete) by which the entire lens including the capsule is removed by rupturing the zonules is termed intracapsular cataract extraction (ICCE). 
The extraction technique that has replaced the ICCE is that of extracapsular cataract extraction (ECCE). 
Phacoemulsification is today the most popular method worldwide and has now virtually replaced all other techniques in most countries.
The cost of equipment is high and the prolonged learning period has prevented it from replacing ECCE globally. 
MATERIALS AND METHODS
This clinical study was performed in the outpatient department at the Alwalidain Charity Eye Hospital to determine the causes of poor visual outcome following ECCE and posterior chamber intraocular lens implantation 6 weeks or more following surgery.
All patients who had ECCE and IOL implantation 6 weeks or more following surgery and who come for regular follow-up were picked from the Statistical Department and assessed for visual acuity, and for those with poor vision uncorrectable with glasses or any other mean of correction, complete ophthalmic examination including pupillary reactions measurement of IOP and direct and indirect ophthalmoscopy were performed.
Poor visual outcome means visual acuity of less than 6/18.
A total number of 100 eyes were studied, 52 were female and 48 were male. Causes of poor visual outcome were found to be the following. [INLINE:1]
In the anterior segment of the eyes, the causes were as follows: Corneal edema, opacity, pannus, bullous keratopathy, detected in 23 eyes (23%), which were contributory factors for poor visual outcome, isolated or with other posterior segment causes. In general, the corneal endothelia cell population decreases with age. Some patients who have had no recorded striation or edema in the immediate postoperative days have, in fact, suffered endothelial cell loss to a critical level.  Nystagmus was met with in two operated eyes of two children, indicating from the beginning poor prognosis following operation of developmental cataracts because of late intervention and defective fixation (stimulus deprivation amblyopia), convergent deviation of the visual axes was met with in two eyes (2%) and divergent deviation was met with in two eyes (2%), indicating strabismic amblyopia associated with developmental and traumatic cataracts; intraocular scarring was found in three eyes (3%), and was the main cause of poor vision in these eyes as a result of organized postoperative hyphema and healed endophthalmitis. IOL decentration detected in five eyes (5%) was a contributory factor of poor vision in 5% of the operated eyes and epithelial down-growth found in one eye with chronic closed angle glaucoma (1% was the cause of poor vision in this eye. This complication is very rare when the limbal incision is completely covered by an intact conjunctival flap.  Posterior capsule opacification met with in 24 operated eyes (24%) was the contributory cause of poor vision beside other factors; sometimes dense as to obstruct vision completely, it remains the most common complication of cataract surgery and is reported to occur in 5-50% of adult patients and nearly 100% of pediatric patients. ,, It is caused by residual lens epithelial cells (LECs), which are inevitably left behind after surgery, and is essentially a wound-healing response of the lens to surgery. ,, Shrunken operated eyes as a result of intraocular infection (endophthalmitis) found in two eyes (2%) were the cause of complete irreversible blindness in these two eyes such that the American society of cataract and refractive sugery (ASCRS) put recommendations about the use of antibiotic as prophylaxis to prevent endophthalmitis; this antibiotic should be commercially available and cover a broad spectrum of organisms, both gram-positive and gram-negative. The antibiotic should also have a low toxicity and excellent pharmacokinetics and pharmacodynamics. 
Amblyopia was detected in six eyes (6%) of the study group: Stimulus deprivation in two eyes (2%) and strabismic in four eyes (4%) were the cause of poor prognosis prior to surgery, which was not predetermined.
In the media and posterior segment, the causes of poor vision and blindness are: Vitreous opacities (vitritis) seen in 23 eyes (23%) - were contributory factors in poor visual outcome mostly as a result of intraocular inflammation or steroid withdrawal. Macular edema was the cause of poor vision detected in 19 eyes (19%). Cystoiv macular edema (CME) is a devastating complication for patients, especially those with premium IOLs, because CME often results in vision loss. Studies have shown that 12% of patients may have retinal thickening following uncomplicated cataract surgery.  Retinal thickening most commonly occurs 4-6 weeks following cataract surgery and is believed to be caused by a prostaglandin-mediated breach of the blood-retinal barrier. 
While diabetic maculopathy was the cause of poor vision in six eyes (6%), glaucomatous optic neuropathy was the cause of poor vision or blindness in 28 eyes (28%), chronic glaucoma unmanaged prior to surgery was detected in 13 eyes (13%), absolute glaucoma was found in three eyes (3%) and pseudophakic glaucoma was detected in 12 eyes (12%) as the reasons for glaucoma are evident from the abnormal anatomical changes induced by surgery; in others, the cause is very complex and may be undetected by the present methods of investigation. 
Age-related macular degeneration was the cause of poor vision in 11 eyes (11%), toxoplasmic macular choroidoretinitis was the cause of poor vision in six eyes (6%), organized macular hemorrhage was detected in one eye (1%), non-glaucomatous optic neuropathy (atrophy) was detected in 19 eyes (19%), retinal detachment was found in six eyes (6%), while vitreoretinal bands were seen in two eyes (2%).
|1||Asbell PA, Dualan I, Mindel J, Brocks D, Ahmad M, Epstein S. Age-related cataract. Lancet 2005;365:599-609.|
|2||Sihota R, Tendon R. Intracapsular cataract extraction. In: Parson's diseases of the eye. 19 th ed, 2003. p. 290.|
|3||Maltzman BA, Haupt E, Notis C. Relationship between age at time of cataract extraction and time interval before capsulotomy for opacification. Ophthalmic Surg 1989;20:321-4.|
|4||Kanski JJ. Posterior capsule opacificatrion. In: Kanski JJ, editor. Clinical ophthalmology, 5 th ed. 2003.|
|5||Kresloff MS, Castellarin AA, Zarbin MA. Endophthalmitis. SurvOphthalmol 1998;43:193-224.|
|6||Frezzotti R, Caporossi A. Pathogenesis of posterior capsular opacification, part I: Epidemiological and clinico-statistical data. J Cataract Refract Surg 1990;16:347-52.|
|7||Nishi O, Nishi K, Wickstrom W. Preventing lens epithelial cell migration using intraocular lenses with sharp rectangular edges. J Cat Refract Surg 2000;26:1543-9.|
|8||Meacock WR, Spalton DJ, Boyce FJ, Jose RJ. Effect of optic size on posterior capsular opacification with 5.5 mm and 6.0 mm optic diameter Acrysof intraocular lenses. J Cataract Refract Surg 2001;27:1194-8.|
|9||Meacock WR, Spalton DJ. Effect of intraocular lens haptic compressibility on the posterior lens capsule after cataract surgery. J Cataract Refract Surg 2001;27:1366-71.|
|10||Barry P, Seal DV, Gettinby G, Lees F, Peterson M, Revie CW. 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;32:407-10.|
|11||Samiy N, Foster CS. The role of nonsteroidalantiinflammatory drugs in ocular inflammation. IntOphthalmolClin 1996;36:195-206. |
|12||Mishima H, Masuda K, Miyake K. The putative role of prostaglandins in cystoid macular edema. ProgClinBiol Res 1989;312:251-64.|