First International Congress on Cataract Surgery Documententa Ophthalmologica Proceedings Series volume 21 Editor H. E. Henkes Dr. W. Junk bv Publishers The Hague-Boston-London 1979 First International Congress on Cataract Surgery Florence, 1978 Edited by J. Francois, E. Maumenee & I. Esente Dr. W. Junk bv Publishers The Hague-Boston-london 1979 Cover design: Max Velthuijs ©DrW. Junk bv Publishers 1979 Softcover reprin of the hardcover 1st edition 1979 No part of this book may be reproduced and/or published in any form, by print, photoprint, microfilm or any other means without written permis sion from the publishers. ISBN·13:978·94·009·9615·1 e·ISBN·13:978·94·009·9613·7 001: 10.1007/978·94·009·9613·7 CONTENTS Session I. Social Aspects of the Cataract. Preparatory and Logistic Problems Chairman: I. Pran~ois R.T. Vyas: Social aspects of the cataract ........ . 1 M.L. Tarizzo: Cataract, a major cause of unnecessary blindness .... . 5 A.I. Bron: Biochemistry of cataract ...................... . 9 I.H. Maumenee: Genetics of cataracts ..................... . 25 P. D'Ermo & P. Steindler: Iatrogenic cataracts ............... . 31 B. Nizetic: Cataract epidemology: Public Health implications and research needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 C.A. Quaranta: General and ophthalmological problems preceding the operation ...................................... . 41 M. Pandolfi: Guidelines of haemorrhagic prophylaxis in cataract surgery ....................................... . 47 M. Ariano & I. Salvoni: General anaesthesia in cataract surgery .... . 57 R. Witmer: Neuroleptanalgesia in ophthalmic surgery ........... . 67 R. Witmer: Local anaesthesia in cataract surgery ... . 69 P. Hervouet: Sterilization .................. . 73 A. Vannini, G.M. Gastaldi & M. Pagiano: Instruments 77 R.C. Troutman: Microsurgery now and in the future ........... . 87 I. Draeger: Recent advances in microsurgical cutting technique 91 Session II. Cataract in the Adult. Experimental Implantation of Crystalline Lens Chairman: I. Barraquer D. Pita-Salorio, M.D. Valera & R.B. Trotta: Lens surgery in the last decades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 97 I. Barraquer: Intracapsular lens extraction. . . . . . . . . . . . . . . . . .. 103 I. Temprano: Directions for the use of alpha-chymotrypsin in enzymatic zonulolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123 C.D. Kelman: Phacoemulsification technique - special considerations. 131 C.D. Kelman: Phacoemulsification - indications, contra-indications and results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 147 C.D. Kelman: Small incision intra-ocular lens. . . . . . . . . . . . . . . .. 155 R.P. Kratz: Extraction by ultrasonic phaco emulsification. . . . . . . .. 171 L.I. Girard: Cataract extraction by ultrasonic fragmentation (USP) .. 173 A.E. Maumenee: Phacoemulsification . . . . . . . . . . . . . . . . . . . . .. 177 L.I. Girard: Pars plana lensectomy with ultrasonic fragmentation (USP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185 F. Pintucci: Indications and techniques of bilateral cataract extraction 193 S. Iwata: Experimental implantation of crystalline lens. . . . . . . . . .. 201 Session III. Congenital Cataract and Cataract in the Young Pathologi cal and Complicated Cataracts Chairman: A.E. Maumenee G. Scuderi & S.M. Recupero: Congenital cataract - surgical problems. 209 W. Duque Estrada: Cataract in the young. . . . . . . . . . . . . . . . . . .. 233 O.-E. Lund: Traumatic cataract. . . . . . . . . . . . . . . . . . . . . . . . .. 235 G. Scassellati Sforzolini: Preferred surgical methods in post-inflamma- tory cataract in young people and adults. . . . . . . . . . . . . . . . .. 237 R. Witmer: Cataract with retinal detachment . . . . . . . . . . . . . . . .. 245 M. Bonnet: Cataract extraction after filtering operation. . . . . . . . .. 249 H. Sautter & U. Demeler: The surgical treatment of sub-luxated lenses 255 D. Paton: Cataract surgery after penetrating keratoplasty. . . . . . . .. 259 R.C. Troutman: Simultaneous cataract extraction and graft. . . . . . .. 269 Session IV. Sutures-Incisions-Wound Healing Intra-operative Complications Chairman: D. Paton I. Essente, A. Molinara, G. Lagana & G. Ambrosini: Choice and clinical evaluation of sutural material . . . . . . . . . . . . . . . . . . .. 273 J.E. Blaydess: An evaluation of 9-0 monofilament polyglactin 910 synthetic absorbable suture in cataract surgery. . . . . . . . . . . . .. 285 R.C. Troutman: The cataract wound: Its closure and healing. . . . . .. 291 D. Paton: Suturing techniques: Continuous and interrupted . . . . . .. 295 R.C. Troutman: Postoperative astigmatism in cataract surgery. . . . .. 307 L. Scullica: The uveal vascular system: Its importance and involv ement with anterior chamber opening. . . . . . . . . . . . . . . . . . .. 311 G. Venturi & L. Barca: Vitreous loss prevention. . . . . . . . . . . . . .. 321 B. Boles Carenini & G. Girotto: Operative complications of cataract surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 331 R.M. Fasanella: Operative complications of cataract surgery . . . . . .. 343 C. Maggi: Eye surgery in a new hyperbaric room (vitreous loss preven- tion). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 347 Session V. Early and Post-operative Complications Particular Clinical Conditions Chairman: R. Troutman F. Pintucci: General and local post-operative treatment . . . . . . . . .. 359 F. Kogure: Inflammatory complication. . . . . . . . . . . . . . . . . . . .. 367 W. Pockley: Bleeding and its control. . . . . . . . . . . . . . . . . . . . . .. 373 M. Bonnet: Treatment of limbic fistule and epithelial invasion of the anterior chamber after cataract extraction. . . . . . . . . . . . . .. 377 M. Bonnet: Pupillary complications after cataract extraction. . . . . .. 385 J. Barraquer: Wound leak, collapse of the anterior chamber choroidal detachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 395 R.A. D'Amico: Membrane formation following cataract surgery. . . .. 409 A.B. Rizzuti: Management of advanced bullous keratopathy past- present-future (prosthokeratoplasty results) . . . . . . . . . . . . . . .. 419 G. Cristini: Aphakic glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . .. 433 M.H. Luntz: Surgical management of aphakic glaucoma. . . . . . . . .. 437 R. Brancato: Maculopathy after intracapsular cataract extraction. . .. 443 M.L. Rosenthal: Retinal detachment in aphakia. . . . . . . . . . . . . .. 455 F.M. Grigno!o: Treatment of retinal detachment in the aphakic ..... 461 J. Fran~ois: Combined operation for cataract and glaucoma . . . . . .. 467 Session VI. Optical and Functional Treatment of Aphakia Chairman: M. Maione D. Paton: Introduction to optical and functional treatment of aphakia 481 A. Alajmo: Psycho-optical aspects of the aphakic condition. . . . . . .. 485 M. Maione & F. Carta: Optical correction of aphakia. . . . . . . . . . .. 489 G.P. Halberg: Extended wearing of contact lenses: An overview. . . .. 493 A. Traykovski & C.F. Traykovski: Silicone lenses in aphakia evalua- tion after one year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 497 B. Mathalone: Keratophakia today. . . . . . . . . . . . . . . . . . . . . . .. 503 Session VII. Intraocu1ar Implants in Extra or Intracapsular Extrac tion. Incidents and Complications with Intraocular Im plants Chairman: A.E. Maumenee D.P. Choyce: The Choyce anterior chamber implants. . . . . . . . . . .. 507 C.D. Binkhorst, Per Nygaard & L.H. Loones: Specular microscopy of the corneal endothelium and lens implant surgery . . . . . . . . . . .. 511 R.P. Kratz: Barraquer Shearing intraocular lens. . . . . . . . . . . . . . .. 529 R. Kern: Unilateral traumatic and complicated cataract in children and young adults as a special indication for intraocular lens implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 531 G. Baikoff: Intra-or extracapsular lens implantation. . . . . . . . . . .. 535 D. Paton: Complications with intraocular lenses. . . . . . . . . . . . . .• 541 J. Barraquer: Complications with intraocular lenses. . . . . . . . . . . .. 545 B. Strampelli: Intraocular implants in extra and intracapsular extrac- tion incidents and complications . . . . . . . . . . . . . . . . . . . . . .. 547 Docum.Ophthal. Proc. Series, Vol. 21 SOCIAL ASPECTS OF THE CATARACT R.T. VYAS (Bombay, India) Indeed, it is a rare privilege for a lay person such as myself to be invited to speak before an august and renowned organisation such as yours. May I at the outset express my sincere gratitude and thanks of my own and on behalf of the Royal Commonwealth Society for the Blind for this unique honour done to me. You the experts have gathered together today to discuss for the first time at International level the 'cataract surgery'. This branch of Ophthalmic surgery has been practised since time immemorial. Cataract surgery and its technique has reference in the ancient Indian Science of Medicine called 'AY UR VEDA' which dates back 5,000 years. While you sit here and delibe rate over new techniques of cataract surgery, there are millions of people in the developing countries of the world who are condemned to lives of perpe tual darkness. Cataract for the developed countries of the world and their citizens really speaking is no problem at all. The onset of cataract for the citizens of the developing world relegates them to a life of utter depen dence, destitution, and degradation. In India alone according to the statis tics provided by the Indian Council of Medical Research five million men and woman today are totally blind because of operable cataract. According to the same organisation in the year 1978, 1.8 million eyes will go blind and would need cataract surgery. What holds good for India is equally true and perhaps more depressing for other countries in the Indian sub-continent and parts of the developing world. Cataract is responsible for 55% of the total cases of blindness in India. Thus it is by far the most dominant factor in causing blindness. The situation is further aggravated by the fact that for the whole of India wit)t a population of over 700 million, we have only approximately 3,500 ophthal mic surgeons. For Bangladesh which has an estimated number of 1 million blind people in a population of 80 million, the number of ophthalmic surgeons is only 25 or thereabout. Most of the Ophthalmic surgeons reside in the towns and cities, while bulk of the population of these countries lives in rural areas. This again makes it impossible for an average villager to receive ophthalmic aid for the restoration of his sight. In Europe and other parts of the developed world, cataract sets in on or after an average age of 60 years. In India the average age at which cataract sets in is 45 years or thereabout. As is well known in the developing countries of the World, there is no old age or disability pension. Thus when a person becomes blind, he is thrown out of employment, has no means of supporting himself and his family which results in gradual starvation and death. MAGNITUDE OF THE PROBLEM It is a contradiction of our age that while the mechanism does exist to cure cataract blindness, it is far too inadequate to meet the colossal nature of the problem. While large cities and towns have facilities, and that too, to a limited extent, the vast majority of the people sit helplessly waiting for the day of deliverance from their miserable existence through death. People just do not go blind in numbers. On paper they are cold statistics but in actual life, they are individuals. Are we going to allow them to pass their days in darkness and destitution? In the Indian sub-continent, 80% of its 850 million people live in the rural areas pursuing traditional agricultural pursuits. When they go blind at an average age of 45 years which according to European standards is almost the 'Youth', you can imagine what will be their predicament. Let us take the example of Shankar. He lives in a small village of Kathor on the bank of the river 'Tapi'; 47 year old Shankar has a wife and 4 young children to main tain. He would leave his home early in the morning much before sunrise to work on a farm. Throughout the day, he would be working under the blazing sun and as the sun set, he would return home with his daily wage of 50 cents. With this money his wife would pay for the purchase of the food and cook the evening meal and possibly a little extra to be used the following morning for Shankar to take with him to his farm. The family of six was without an income for almost two years when Shankar could no longer work because of 'cataract'. His wife did some chores for the neighbours and earned a little income to keep the family of six alive. Shankar resigned himself to the will of God thinking that he was destined to be blind. EYE CAMPS One day news came to the village that eye doctors were camping in the near by village to provide free treatment. A Rotary Club with the help of the Royal Commonwealth Society for the Blind had organised an eye camp. By word of mouth, by beating the drum and through posters people having eye trouble were notified to go to the eye camp. A school building was converted into a temporary Eye Hospital Desks and tables were removed; rooms washed and beds laid for the operated pa tients. The Rotarians worked as volunteers, patients queued up in the school compound for registration. Some came walking from miles away, some used the bullock cart, while some came by buses praying that they would get back their sight. An unassuming quiet looking gentleman in simple clothes examined the patients, in an improvised dark room. He was Dr. R.R. Doshi. It was Shankar who was sitting before Dr. Doshi, blind due to bilateral 2 cataract. Shankar was admitted to the eye camp and operated in one eye. On the seventh day when the bandages were finally removed, Shankar saw the light for the first time after two years. His joys knew no bounds. Throughout the duration of the camp in which over 260 people were operated for cataract in three days time, free food was provided to the patients and their relatives. Each year, the Royal Commonwealth Society for the Blind in 22 States of India, in Bangladesh and in Pakistan supports over 1,500 rural eye camps. For the year ended 31st December, 1977, eye camps supported by the Royal Commonwealth Society for the Blind in co-operation with Lions Clubs, Rotary Clubs and other Organisations examined the eyes of 668,826 Indian villagers and restored sight to 85,176 cataract blind men and woman. EYES OF INDIA CAMPAIGN Since 1970, when the Royal Commonwealth Society for the Blind launched the eyes of India campaign, the eyes of over a million people were examined and treated and sight of more than 4,00,000 totally blind people restored. India has about 12,000 ophthalmic beds in its hospitals which are mainly in towns and cities. Its 3,500 ophthalmic surgeons are based in towns and cities. Eye camps are the only means which can help to restore sight to cataract blind people. STRATEGY The Government of India have evolved a national programme for the Con trol of Blindness and Visual impairment. Under this programme mobile ophthalmic units will eventually cover the rural areas of India and base hospitals in the rural areas will be set up to provide ophthalmic treatment. Till this becomes fully operative, eye camps will have to continue to play an effective role. SUPPORT OF THE OPHTHALMOLOGISTS Ever since Sir John Wilson, President of the International Agency for the Prevention of Blindness and Director, Royal Commonwealth Society for the Blind, addressed the Indian Ophthalmic Society in 1973, the ophthalmic surgeons are coming forward in large numbers to give their free services in the rural eye camps. Careful scrutiny of eye camps statistics have given very encouraging results. The rate of success at an eye camp is as high as 94%. Bearing in mind that these eye camps are held in improvised hospital-like accomodation, these statistics are indeed very heartening. 100 CATARACT OPERATIONS IN A DAY At an eye camp, the day begins before sunrise, and by the time sun sets, one eye surgeon does as many as 100 cataract operations. Yes, 100 cataract operations, which will be unbelievable for most ophthalmologists, in the 3