Letter. Is there still a place for intra-capsular cataract extraction or should it be relegated to the history books?
Since cataract is the most common cause of world blindness in nearly all less-developed countries, one of the major thrusts in blindness prevention and in the programme ‘Vision 2020: The Right to Sight’ is in making cataract surgery available to all. All the major agencies concerned with blindness prevention, such as the International Agency for the Prevention of Blindness, as well as non-governmental organisations and charities, seem to be strongly recommending extra-capsular cataract extraction with lens implant as the operation of choice. No-one would dispute that this is the most effective procedure with the lowest complication rates, provided that all the necessary equipment is available. Unfortunately, in much of the world the necessary equipment is not yet available nor is it likely to be for some years yet. Certainly there are very many surgeons doing extra-capsular cataract surgery who do not have access to a YAG laser, and there are considerable numbers who may not have an operating microscope at all, or, if they do have one do not have reliable coaxial illumination. When some or all of these facilities are not available then the results of extra-capsular surgery are not satisfactory and may indeed be worse than the results of intra-capsular surgery.
Effective intra-capsular cataract surgery requires neither an operating microscope nor a YAG laser and anterior chamber lens implants, provided they are of the correct design and the correct size, appear to be perfectly stable and free of long-term complications, certainly as far as patients over 60 are concerned.
The recent change to recommending extra-capsular cataract surgery and lens implants has come for three reasons:
- intra-ocular lenses have become very much cheaper
- numerous surveys have shown that many aphakic patients without implants are either never given spectacles or if given them have lost or broken them
- the excellent results of extra-capsular surgery with lens implants in the industrialised world.
I would like to suggest that whilst lens implant surgery should be strongly recommended and promoted, we should not condemn an intra-capsular extraction with an anterior chamber lens implant until a good audit and a retrospective analysis has shown that the results of this are significantly inferior to extra-capsular extractions in situations where YAG lasers and top quality microscopes may not be available.
My reason for writing this letter is a consequence of two recent events. I have just visited northern Nigeria and found that the method of cataract surgery which has increased more than other methods, over the last 15 years, is, in fact, couching rather than modern cataract surgery. Also, I have heard that the DU-AL Corporation, which for many years has made excellent low cost cryo-extractors for intra-capsular extraction, has been facing an uncertain future.
I would be grateful for your readers’ views about this important subject which I feel has not been discussed as fully as it should.