Letter. Cataract surgery
I agree with John Standford-Smith (J Comm Eye Health 2000; 13: 62) that intracapsular cataract extraction (ICCE) has been relegated to the history books without necessary discussion taking all the facts into account.
Like others in the 80s, I trained to do ICCE using a loop. We face the choice of having to retrain to carry out ECCE + PCIOL, or continue to practice what is increasingly regarded as a substandard technique.
While ICCE has its complications (vitreous loss, macular oedema, retinal etachment, etc.), so does ECCE even when ‘erformed in good conditions (posterior apsule opacification, etc.). Perhaps the truth is that all methods can give sub-optimal results despite the best of intentions.
At the Bamako, Mali, launch of Vision 2020, Dr Daniel Ety’aale of the WHO, reminded delegates that the majority of ophthalmologists in Francophone West Africa had only been trained in ICCE.
As John Standford-Smith suggests, anterior chamber IOLs are a useful way forward, enabling surgeons doing ICCE to offer their patients the benefits of pseudoaphakia.
Another factor in the ICCE/ECCE debate is cost. To set up for ECCE + PCIOL requires more expensive equipment than for ICCE+ACIOL (microscope, YAG laser, etc.) The extra consumables for ECCE+PCIOL are more expensive and less easily produced locally (Ringer’s lactate solution, methyl cellulose, nylon sutures, maintenance of expensive equipment, etc.). The main consumables for ICCE + ACIOL are the cryo refrigerant and the sutures. Now that ozone friendly refrigerants are available in many African cities, this is less of a problem.
Also, certain types of cataract such as intumescent with a tough capsule, hypermature with a shrivelled cortex are better dealt with by ICCE. In this part of Africa, these types of cataract are still very common.
Perhaps we need a certain amount of humility in realising that a mixture of methods is needed to deal with the many varied types of cataract that we meet. We also need to take into account what our patients can realistically afford.