Simultane Bilateral Fakoemulsifikasyon ve Göz İçi Lens İmplantasyonu

1. 1Dünya Eye Hospital, Istanbul, Turkey
2. 2Çanakkale Onsekiz Mart University, School Of Medicine, Department Of Ophthalmology, Çanakkale, Turkey
3. 3Dr. Lütfi Kirdar Kartal Research And Training Hospital, Eye Clinic, Istanbul, Turkey
4. 4Kocaeli Darica Farabi State Hospital, Kocaeli, Turkey
5. 5Istanbul Kartal Yavuz Selim State Hospital, Istanbul,?Turkey

Sorumlu Yazar: Bilateral phacoemulsification was introduced during the regular cataract process in 1990s with encouraging initial results.5-16 A number of authors have reported their experiences with simultaneous bilateral cataract surgery with excellent results comparable to unilateral cataract surgery.5-15 Keskinbora is the first author who performed and reported the results of bilateral simultaneous cataract surgery from Turkey.3,5 However, similar to the worldwide tendency, this approach could not find enough supporters in Turkey, either. The results of a cataract survey performed among Turkish ophthalmologists demonstrated that only 4.5% of the surgeons performed bilateral simultaneous cataract surgery.17 The intraoperative complication rates of simultaneous bilateral cataract surgery reported are between 0.25% and 7.7%3,11 , and are between 7% and 7.5% for unilateral cataract surgery from the data of 2 national surveys from the UK.18,19 The incidence of intraoperative complications in our study was 7.2% (n=50), of which the ruptured posterior capsule with vitreous loss (n=20, 2.89%) and without vitreous loss (n=17; 2.45%) was the most encountered problem. The reported rates of posterior capsular rupture vary between 0.46% and 4.4% in most institutions.19-21 Vitreous exposure is the most important intraoperative complication which increases the risk of endophthalmitis 1.8 times to 16 times and also increases the risk of postoperative cystoid macular edema.22 Previously published rates of posterior capsular rupture and vitreous loss during phacoemulsification are between 1.4-5.2% and 0.7-2.3%23-25, and during extracapsular cataract extraction (ECCE) are between 0-8% and 0.09-3.3%, respectively.18,26-28 Potamitis and colleagues reported no complications among 66 cases of immediate sequential cataract surgery (ISCS).9 In the current study, the zonular dehiscence obstructing the surgery was the second most encountered problem (9 eyes; 1.3%). The zonular dehiscence incidence was reported to be between 0.46-0.67%.20,29 Pseudoexfoliation occurred in 6 of 9 eyes with zonular dialysis, while all had dense cataracts and were over 70 years of age. Patients with pseudoexfoliation are at an increased risk for the development of complications. Pseudoexfoliation occurred in 43 (6.2%) of 692 eyes. Abbasoglu et al., reported a 2.5-fold risk of vitreous loss in eyes with pseudoexfoliation.30 Elderly age, high rate of pseudoexfoliation co-existence and a dense nuclear cataract were the most common types of comorbidities that may be responsible for the higher zonular dialysis rate and posterior capsular perforation with and without vitreous exposure in our study. The patient with nucleus drop in the second eye was a 76-year-old woman with a dense cataract and zonular dialysis of 270 degrees; the drop occurred during the rotation of the lens. Arshinoff reported 1,020 consecutive patients (2,040 eyes) who underwent bilateral surgery.11 Of 32 complications, 4 patients suffered posterior capsular ruptures, 1 with vitreous loss.11 This complication rate is far less than in our study. However in Turkey, most of the elderly patients, especially in the rural areas, seek help only when their visual acuity decreases to the extent that they cannot perform their daily routines which in turn causes more dense and more mature cataracts. The mean age of our patients was 73.16 years. Higher patient age is a significant risk factor for intraoperative complications due to weaker zonules, denser cataracts, smaller pupils, and higher co-existence of systemic diseases such as diabetes, hypertension, and glaucoma. Two hundred eighty four (82%) of our patients were over 65 years old. The main concern of the surgeons in regards to performing bilateral intraocular surgery was the doubled risk of complications, especially endophthalmitis, by performing two surgeries on the same person. The reported rates of unilateral endophthalmitis after bilateral cataract surgery is between 0.07-0.19%.7,8,15 Four cases of bilateral endophthalmitis encountered after bilateral simultaneous cataract surgery are reported in the literature.6,31-33 In these three cases, there were deficiencies in septic protocols such as using the same surgical instruments, using the same irrigation solutions or absence of prophylactic antibiotics.6,31,32 However, the last case of bilateral endophthalmitis was reported in 2008 although a separate septic protocol was used for each eye.33 In the current study of 692 eyes, we had no endophthalmitis cases unilaterally or bilaterally to date. Although the rates of posterior capsular tear with and without vitreous exposure in our study seem to be higher than in the literature, our patients were protected from the horrifying complications of endophthalmitis (unilateral or bilateral) due to the routine use of povidone-iodine and with the appropriate draping of the surgical field excluding the eyelashes and the use of 1 mg in 0.1 mL of intracameral cefuroxime at the end of the surgery. The recently published incidence rates of postoperative endophthalmitis after immediate sequential bilateral cataract surgery (ISBCS) were reported by Archinoff and Bastianelli to be 1 in 5759 cases with a reduction to 1 in 14352 cases with intracameral antibiotics.34 For unilateral cataract surgery, reported rates of postoperative endophthalmitis range from 0% to 0.20% after uneventful phacoemulsification but may increase to 2.0% to 2.42% in complicated cases12,14,22,35-38 and endophthalmitis associated with simultaneous bilateral cataract surgery has been reported to occur in 0% to 0.19% of eyes.7,8,14,39,40 The European Society of Cataract and Refractive Surgeons (ESCRS) study demonstrated that a single dose of 1 mg in 0.1 mL of intracameral cefuroxime at the conclusion of surgery reduced the risk of endophthalmitis by a factor of almost five, from 0.34% down to 0.07%.41 Nuclear drop is the other important and frightening complication in cataract surgery. In one patient who had diabetes mellitus and pseudoexfoliation, a nuclear drop with zonular dehiscence of nearly 270 degrees occurred during the operation of the second eye, after the uncomplicated regular cataract surgery of the first eye. We finished the surgery and left the patient aphacic. Later on, posterior vitrectomy and scleral fixated IOL implantation were performed. However, on the follow-up, she developed cystoid macular edema (CME) and lost 2 lines of visual acuity compared to the preoperative visual acuity assessment. If nuclear drop had occurred during the first operation, we would have cancelled the operation of the second eye. Suprachoroidal hemorrhage rates vary depending on the method used for cataract extraction, and the criteria used for diagnosis. We have been able to find some reports of bilateral suprachoroidal hemorrhage associated with cataract surgery.42-44 There were no cases of suprachoroidal hemorrhage associated with simultaneous bilateral phacoemulsification or ECCE.7-11,45 The final BCVA increased in 633 (91.5%) eyes, decreased in 12 (1.7%) eyes, and remained the same in 47 (6.8%) eyes. As can be seen easily from the preoperative VA data, in Turkey, patients suffer long waiting times for cataract surgery which leads to very hard, dense cataracts and increases the risk of zonular dehiscence which may obscure the surgery and lead to higher peri- or postoperative complications. We conclude from the results of this study that if each eye is treated as a completely separate procedure in experienced hands with the application of strict exclusion criterion, bilateral phacoemulsification in selected cases may be another option for speeding up visual rehabilitation of patients with bilateral cataracts. This can reduce costs both for the general healthcare system and the patient and is not disadvantageous compared with the reported results and complication rates of separate bilateral cataract surgery. Since the risk of bilateral complications cannot be disregarded, we, of course, can not recommend simultaneous bilateral surgery to all patients without balancing risk factors to advantages. Address for Correspondence/Yazisma Adresi: Levent Akçay MD, Dünya Eye Hospital, Istanbul, Turkey Phone.: +90 216 554 46 46 E-mail: levent.akcay@dunyagoz.com Received/Gelis Tarihi: 09.11.2012 Accepted/Kabul Tarihi: 11.01.2013