Safety and efficacy of manual small incision cataract surgery for phacolytic glaucoma

In this issue Venkatesh and coworkers (see page 279) from The Aravind Eye Hospital in Pondicherry, India present their results of utilizing a manual sutureless extracapsular cataract surgery (MSICS) technique to treat thirty three consecutive cases of phacolytic glaucoma.¹ Pre‐operatively the mean intraocular pressure was 46.2 mmHG. Post‐operatively the IOP was 22 mmHg or less in all cases and 87.9% achieved a post‐operative visual acuity of 20/60 or better! They had no major complications. There were no expulsive hemorrhages and not a single case of posterior capsule rupture. These results are spectacularly good and point out the efficacy of sutureless manual extracapsular cataract extraction. The surgical technique they describe is not only much faster and far less expensive than phacoemulsification for mature cataracts, but it may well be a better and safer technique in the most advanced cases, particularly when phacolytic glaucoma is present. The definitive treatment for phacolytic glaucoma is surgery to remove the lens. However, phacolytic glaucoma presents a very challenging problem for the surgeon. In most cases the lens changes are very advanced. The pathology includes micro‐leakage of high molecular weight proteins through an intact anterior lens capsule. This leads to inflammation and obstruction of aqueous outflow causing a rise in intraocular pressure. The high intraocular pressure increases the risk of a suprachoroidal hemorrhage during surgery. In addition, the residual nucleus is usually rock‐hard with little or no epinucleus remaining. These factors increase the risk of posterior capsule rupture or corneal damage with ultrasound emulsification of the lens. Finally, zonulysis often accompanies the lens changes making the surgery and lens implantation even more difficult. The self sealing tunnel incision of the surgical technique described in this paper maintains the anterior chamber and intraocular pressure during surgery providing the same safety against expulsive hemorrhage as a clear corneal phacoemulsification wound. The continuous curvilinear capsulorrhexis, performed after trypan blue staining, allows for “in the bag” intraocular lens placement and use of a capsule tension ring when needed. The gentle visco‐irrigation of the residual nuclear disc from the bag and out of the eye protects both the lens capsule and the corneal endothelium. As the reported results attest, MSICS is an excellent approach to these challenging cases. Morgagnian cataracts, phacomorphic‐glaucoma, black cataract nigra and brown cataracts with leathery capsules fused to the nucleus all present unique challenge that may also be better addressed with MSICS techniques rather than phacoemulsification. A report from Pradhan and Hennig from the Sagarmartha Choudhary Eye Hospital in Lahan, Nepal reported a series of 413 cases of lens induced glaucoma. Of these, 72% were phacomorphic.