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Post-operative outcomes of phacoemulsification by senior resident

Purpose: To study post-operative outcomes of phacoemulsification in 25 cases done by senior resident. Materials and Methods: This was retrospective, interventional study done after obtaining written informed consent from patients. Any patient having immature cataract (up to Grade 3 nuclear sclerosis) and operated by same senior resident for phacoemulsification were included in study. Patient with brown and mature cataracts and any ocular co-morbidities were excluded. A detailed history and examination of visual acuity and best corrected visual acuity (BCVA) for distance and near, anterior segment with slit lamp biomicroscope and posterior segment with direct/indirect ophthalmoscopy was done and cataract was graded. Phacoemulsification was done by divide and conquer technique in all cases. Patient was examined on 1 post-operative day, 1 week post-operatively and 1.5 months post-surgery for BCVA, corneal edema, iridocyclitis, intraocular pressure (IOP) and endothelial cell count (ECC). Visual recovery, duration of full recovery, resolution of corneal edema and iridocyclitis, rise in IOP, count of endothelial cells after surgery were analyzed. Results: All patients got BCVA ≥ 6/9 at final follow-up, no patient had residual corneal edema or iridocyclitis after 2 weeks. One patient developed IOP rise due to steroid response which was controlled medically. There was 11.6% loss of ECC at final-follow up visit. Conclusion: Divide and conquer method of phacoemulsification is safe in beginner’s hands with no significant difference in long term visual outcomes, however recovery takes long time compared to experienced surgeon.


Introduction
The commonest cause of preventable blindness and low vision is cataract. 1,2 Till now, no effective non-surgical treatment for cataract is available. Surgeries for the treatment of cataract are the commonest surgical procedure in ophthalmology. 3 Phacoemulsification (phaco) with insertion of intraocular lens (IOL) has become the procedure of choice for dealing with cataract. 4 Phaco permits removal of cataractous lens through a smaller incision and quicker visual recovery. But like every surgery, phaco has its own learning curve. There are chances of some complications or initial slower recovery when surgery is done by a senior resident who is relatively inexperienced compared to other experienced surgeons. Hence, post-operative outcomes of phacoemulsification done by a beginner surgeonsenior resident is being studied here.

Materials and Methods
This was a retrospective, interventional study done from a period of May 2018 to August 2018 after obtaining clearance from Institutional Ethical Committee and written informed consent was taken from all the patients. We analyzed post-operative outcomes in first 25 cases operated by phacoemulsification by senior resident. This study was done at G. T. Sheth Ophthalmological Hospital, P. D. U. Govt. Medical College, Rajkot. Any patient having immature cataract (up to Grade 3 nuclear sclerosis) and operated by same senior resident were included in the study. Patients with brown and mature cataracts, pediatric patients and those other ocular co-morbidities, endothelial count < 1500 cells/mm 2 were excluded from the study. A detailed history, examination of visual acuity and best corrected visual acuity (BCVA) for distance and near, anterior segment examination with slit lamp biomicroscope and posterior segment examination with direct/indirect ophthalmoscope was done. Cataract was graded. Intraocular pressure (IOP) measurement was done by Goldmann's Applanation tonometer and sac syringing was performed. Pre-operative endothelial cell count (ECC) was done by non-contact specular microscope. Keratometry was done by automated keratometer and axial length was done by contact A-Scan ultrasound and IOL power was calculated. Urine sugar testing, Random blood sugar (RBS), Blood pressure (BP) measurement, Human Immunodeficiency Virus (HIV), Hepatitis B Surface Antigen (HBsAg) testing was done in all cases. In diabetics, post prandial blood sugar (PP2BS) and fasting blood sugar (FBS) were also measured.
Pre-operatively, pupils were dilated with tropicamide (0.8%) + phenylephrine (5%) eye drops instilled 3 times at the interval of 10 minutes, followed by cyclopentolate (1%) eye drops 3 times at the interval of 10 minutes followed by flurbiprofen (0.03%) eye drops 3 times at the interval of 10 minutes. After all aseptic precautions, surgery was started.
Peribulbar anesthesia (4 ml 2% lignocaine + 4 ml 0.5% bupivacaine mixed with 15 IU/ml of hyaluronidase) was given and super pinky ball was applied for 10 minutes. After that, painting with 10% povidone iodine was done and draping was done. Wire speculum was applied. Superior rectus bridle suture was taken. 2 side ports were made at 10 and 2 o' clock with 15 degree knife. 2% Hydroxypropylmethyl cellulose (HPMC) (viscoelastic) was injected into anterior chamber (AC). Continuous curvilinear capsulorrhexis (CCC) was done using 26 G needle bent as a cystitome. Conjunctival peritomy was done at 12 o' clock and hemostasis was achieved with bipolar wet field cautery. 3 mm scleral incision was made with 15 No. surgical blade.
Tunnel was made with crescent blade. Triplanar entry was done into AC using 2.8 mm keratome. Viscoelastic was injected and hydro-dissection was done followed by hydrodelineation. In cases with posterior polar cataract, only hydrodelineation was done. Nucleus was rotated freely into capsular bag and then phacoemulsification was done by 'divide and conquer' technique. Phaco tip was kept at iris plane in all cases. In the bag phaco was done in all cases. Settings for phaco 1 and phaco 2 and phaco 3 were as mentioned in Table 1. Cortical clean up was done with bimanual irrigation-aspiration canula. Hydrophilic acrylic foldable IOL was inserted with injector system under viscoelastic cover. Viscoelastic wash was done and all 3 ports were hydrated. 2 cases required suturing of main port at 12 o' clock. Superior rectus suture was removed and subconjunctival antibiotic-steroid injection (Amikacin 50 mg + Dexamethasone 2 mg) was given, povidone iodine wash was done and speculum was removed and eye was patched. Duration of surgery ranged from 25-40 minutes. Postoperatively, antibiotic steroid eye drops (Ofloxacin 0.3% + Dexamethasone 0.1%) were given 6 times/day for 1 week followed by 4 times/day for 1 month followed by 2 times/day for 1 month. Patients were examined on 1 st post-operative day, 1 week post-operatively and 1.5 months post-surgery for BCVA, status of corneal edema, iridocyclitis, intraocular pressure (IOP) and endothelial cell count (ECC). Visual recovery, duration of time for full recovery, resolution of corneal edema and iridocyclitis, rise in IOP, count of endothelial cells after surgery were analyzed.

Results
This was a retrospective, interventional study done from a period of May 2018 to August 2018 in which we analyzed post-operative outcomes in first 25 cases operated by phacoemulsification by senior resident. Out of 25 patients, 14 were males and 11 were females. Right eye was operated in 9 and left eye was operated in 16 patients. Age group of patients included was from 45 to 86 years with mean age being 63 ± 10.54 years. According to grading of cataract, 6 patients were having nuclear sclerosis grade 1, 9 patients were having nuclear sclerosis grade 2 and 10 patients were having nuclear sclerosis grade 3 cataract. Mean pre-operative best corrected visual acuity (BCVA) in logMAR (logarithm of mean acuity of resolution) was 0.83 ± 0.32. Mean endothelial cell count (ECC) pre-operatively was 2395.48 ± 248.27 cells/mm2. Mean age, mean pre-operative BCVA and mean pre-operative ECC as per nuclear grade is shown in Table 2.
All patients got BCVA ≥ 6/9 at final follow-up visit 1.5 months post-operatively. Mean pre-operative BCVA in logMAR was 0.83 ± 0.32. Mean post-operative uncorrected visual acuity (UCVA) in logMAR was 0.18 ± 0.15 and mean post-operative BCVA in logMAR was 0.05 ± 0.08. Compared to pre-operative BCVA, mean improvement in post-operative UCVA is 4 lines of Snellen's visual acuity chart and mean improvement in post-operative BCVA is 5 lines of Snellen's visual acuity chart. Mean post-operative visual acuity in logMAR and improvement in visual acuity as per the grade of nuclear cataract is shown in Table 3.
No patient had residual corneal edema or iridocyclitis after 2 weeks. One patient developed IOP rise due to steroid response which was controlled medically.

Discussion
Several studies have studied outcomes of phacoemulsification but most of them studied outcomes of phacoemulsification done by experienced surgeons. Very few studies have studied outcomes of phacoemulsification done by a beginner and relatively inexperienced surgeon. There are chances of some complications or initial slower recovery when surgery is done by a senior resident who is relatively inexperienced compared to other experienced surgeons.
Hence, post-operative outcomes of phacoemulsification done by a beginner surgeonsenior resident is being studied here. Age group in this study was from 45 to 86 years mean being 63 years which is comparable to the study done by Paul O' Brien et al. in which mean age was 71 years. 5 We included cataracts up to grade 3 nuclear sclerosis in our study because grade 4 hard brown cataracts are known to have poor post-operative outcome by phacoemulsification in hands of inexperienced surgeons. Mean pre-operative BCVA and ECC in all 3 nuclear grades were comparable. BCVA was lesser in cataracts of higher nuclear grade because of density of cataract. However, there was no difference in post-operative UCVA or BCVA at final 1.5 months post-operative visit. Visual recovery was comparatively delayed in cataracts of higher density nuclear grade because of post-operative keratitis and iritis which was more found in grade 3 nuclear cataract. All patients got BCVA ≥ 6/9 at final follow-up visit 1.5 months postoperatively which is comparable to the study done by Hyung Bin Hwang et al. 6 Endothelium of cornea plays important role in the corneal transparency. Endothelium is arranged in single layer and is non-healing. Endothelium may be damaged during ocular surgeries. Apart from mechanical damage endothelium may be damage by the temperature of fluid inside the anterior chamber. 7 During phaco temperature in the anterior chamber may be increased by various reasons which produce potentially dangerous heat which damages endothelium. Important factors include, vibaration of the phaco tip and ultrasound power used. 8 In one study the oxidative tissue damage of the corneal endothelium during phaco was found to be correlated with the ultrasonic energy applied. 9 Mode of phaco applied during surgery is important, effect of continuous vs pulse and burst mode was studied and it was noted that serious corneal edema occurred more frequently in continuous group than that in the pulse and burst groups. 10 Whether supervised or unsupervised the complications of phaco procedure were more by the beginner than by experienced phaco surgeon. Corneal endothelial cell damage can induce corneal decompensation after phacoemulsification, especially in high-risk groups. Thus, endothelial cell loss is an important prognostic factor of the outcome of phacoemulsification surgery. Our study found 11.6% loss of endothelial cells count at 1.5 months follow up which is comparable with study done by Reuschel et al. who reported ECC loss of 4.5-7.9% 3 months after phacoemulsification and Park et al. demonstrated ECC loss of 5.2-9.1% two months after phacoemulsification. 11,12 However, long term results of visual acuity and ECC were comparable with surgery done by experienced surgeons.

Conclusion
Divide and conquer method of phacoemulsification is safe in beginner's hands with no significant difference in long term visual outcomes, however recovery takes long time compared to experienced surgeon.