Small incision manual technique fills need in remote parts of developing countries

New surgical techniques and changing concepts of pricing and practice structure mean better care for those blinded by cataract.

Phacoemulsification and small incision cataract surgery are becoming more common in developing nations such as Nepal, according to one physician in that country.

“I see [small incision cataract surgery] with temporal incision as a strong surgical technique coming up in this part of the world,” Sanduk Ruit, MD, said.

Dr. Ruit described the progress he and his colleagues have made in treating cataract blindness, a problem that he said remains particularly challenging in rural areas of developing countries.

“The patients who are affected with blindness are unequivocally deprived socially and economically. They often have very advanced cataract, and they are distant from transportation and other amenities,” Dr. Ruit said.

Dr. Ruit said phacoemulsification is still in the future for surgeons in underdeveloped nations. He and his colleagues at the Tilganga Eye Center in Kathmandu have been developing a sutureless manual cataract technique that he said will be useful in remote communities, avoiding the need for expensive devices that are difficult to transport.

Small incision technique

Over the past 2 years, Dr. Ruit and colleagues have modified the small incision manual technique from a superior incision to a temporal incision for better postoperative visual results.

The self-sealing incision is 6 mm to 7 mm externally, widened to 10 mm internally
The self-sealing incision is 6 mm to 7 mm externally, widened to 10 mm internally.

The technique involves removal of the whole nucleus by flushing it forward into the anterior chamber, Dr. Ruit said during a telephone interview with Ocular Surgery News. An external, self-sealing wound of 6 mm to 7 mm is made with either a metal crescent or diamond knife, Dr. Ruit said. Then a keratome is used to enlarge the internal opening of the incision to 10 mm.

For mature cataracts, Dr. Ruit said, a straight needle is used to make a triangular capsulorrhexis.

The infusion stage of the procedure begins with the introduction of a 21-gauge irrigation/aspiration cannula, Dr. Ruit said.

“A large infusion helps maintain the anterior chamber during our manipulations so that we don’t touch the back of the cornea,” Dr. Ruit told Ocular Surgery News.

Step 1 of the infusion stage is to hydrodissect the nucleus in order to push it from the capsular bag into the anterior chamber. In step 2, the nucleus is extracted through the outer wound.

“We let the fluid collect below the nucleus and let the fluid float the nucleus into the wound,” Dr. Ruit explained.

Dr. Ruit said he uses a corrugated Simcoe I&A cannula (Indo-German) to grab the nucleus and extract it from the eye. The remaining cortical matter is cleaned out, and air or viscoelastic is injected for lens implantation.

To enhance the speed of patient turnover, the surgeon sits in one place while performing surgery, regardless of whether the case is a right or left eye, according to Dr. Ruit

“We have the table a little longer than the normal table. The surgeon sits in the center, and the right eye patients come from the right side and the left eye patients come from the left side, so the surgeon is actually not moving, and he is always working on the temporal side of the patient,” he said.

One-piece PMMA IOL One-piece PMMA IOL One-piece PMMA IOL

The one-piece PMMA IOL (A, B, C) manufactured at Tilganga Eye Center is shown in the eye under different illuminations.

Images: Ruit S

Good visual results with small incision

In an analysis of more than 5,000 surgeries performed at Tilganga Eye Center, Dr. Ruit compared his small incision technique to phaco. His results showed that while uncorrected and corrected visual acuity in both techniques were comparable at 6-week and 6-month follow-up, a higher proportion of the small incision patients had visual acuity better than 6/18 at 1 year.

He also found that 82% of patients with a temporal incision had uncorrected visual acuity of 6/18 or better compared to 50% of patients with a superior incision. All but two patients in the temporal-incision group had 2 D or less of postoperative astigmatism, and none had more than 3 D. In the superior incision group, astigmatism ranged up to 4 D.

“If we can bring this quality, which is comparable to phaco but at much lesser cost, then I think it will be a thing that can be used in remote areas where there are large volumes of cataract patients who are having difficulties in going to seek their services in the big cities,” Dr. Ruit said.

As part of a program to bring cataract surgery to the people who need it most, Dr. Ruit and colleagues practice what he calls social marketing to combat issues of distance, price and quality that hinder patients from accepting help.

Dr. Ruit said they use a form of payment in which operations for the poor are subsidized by operations for the wealthy. “The paying patient pays for the poor patient,” he said.

For more information:
  • Sanduk Ruit, MD, can be reached at the Tilganga Eye Center, GPO 561, Gaushala Bagmati Bridge, Kathmandu, Nepal; +977-1-449-3746; e-mail: sruit@tilganga.com.np. Ocular Surgery News was unable to determine whether Dr. Ruit has a direct financial interest in the products discussed in this article or if he is a paid consultant for any companies mentioned.
  • Indo-German surgical corporation, maker of the corrugated Simcoe cannula, can be reached at 123 Kaliandas Udyog Bhuvan, Near Century Bazar, Prabhadevi, Mumbai 400025; +91-22-2422-1809; fax: +91-22-2430-5894; e-mail: indogem@bom3.vsnl.net.in; Web site: indogerman.com.
  • Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology.

Phacoemulsification and small incision cataract surgery are becoming more common in developing nations such as Nepal, according to one physician in that country.

“I see [small incision cataract surgery] with temporal incision as a strong surgical technique coming up in this part of the world,” Sanduk Ruit, MD, said.

Dr. Ruit described the progress he and his colleagues have made in treating cataract blindness, a problem that he said remains particularly challenging in rural areas of developing countries.

“The patients who are affected with blindness are unequivocally deprived socially and economically. They often have very advanced cataract, and they are distant from transportation and other amenities,” Dr. Ruit said.

Dr. Ruit said phacoemulsification is still in the future for surgeons in underdeveloped nations. He and his colleagues at the Tilganga Eye Center in Kathmandu have been developing a sutureless manual cataract technique that he said will be useful in remote communities, avoiding the need for expensive devices that are difficult to transport.

Small incision technique

Over the past 2 years, Dr. Ruit and colleagues have modified the small incision manual technique from a superior incision to a temporal incision for better postoperative visual results.

The self-sealing incision is 6 mm to 7 mm externally, widened to 10 mm internally
The self-sealing incision is 6 mm to 7 mm externally, widened to 10 mm internally.

The technique involves removal of the whole nucleus by flushing it forward into the anterior chamber, Dr. Ruit said during a telephone interview with Ocular Surgery News. An external, self-sealing wound of 6 mm to 7 mm is made with either a metal crescent or diamond knife, Dr. Ruit said. Then a keratome is used to enlarge the internal opening of the incision to 10 mm.

For mature cataracts, Dr. Ruit said, a straight needle is used to make a triangular capsulorrhexis.

The infusion stage of the procedure begins with the introduction of a 21-gauge irrigation/aspiration cannula, Dr. Ruit said.

“A large infusion helps maintain the anterior chamber during our manipulations so that we don’t touch the back of the cornea,” Dr. Ruit told Ocular Surgery News.

Step 1 of the infusion stage is to hydrodissect the nucleus in order to push it from the capsular bag into the anterior chamber. In step 2, the nucleus is extracted through the outer wound.

“We let the fluid collect below the nucleus and let the fluid float the nucleus into the wound,” Dr. Ruit explained.

Dr. Ruit said he uses a corrugated Simcoe I&A cannula (Indo-German) to grab the nucleus and extract it from the eye. The remaining cortical matter is cleaned out, and air or viscoelastic is injected for lens implantation.

To enhance the speed of patient turnover, the surgeon sits in one place while performing surgery, regardless of whether the case is a right or left eye, according to Dr. Ruit

“We have the table a little longer than the normal table. The surgeon sits in the center, and the right eye patients come from the right side and the left eye patients come from the left side, so the surgeon is actually not moving, and he is always working on the temporal side of the patient,” he said.

One-piece PMMA IOL One-piece PMMA IOL One-piece PMMA IOL

The one-piece PMMA IOL (A, B, C) manufactured at Tilganga Eye Center is shown in the eye under different illuminations.

Images: Ruit S

Good visual results with small incision

In an analysis of more than 5,000 surgeries performed at Tilganga Eye Center, Dr. Ruit compared his small incision technique to phaco. His results showed that while uncorrected and corrected visual acuity in both techniques were comparable at 6-week and 6-month follow-up, a higher proportion of the small incision patients had visual acuity better than 6/18 at 1 year.

He also found that 82% of patients with a temporal incision had uncorrected visual acuity of 6/18 or better compared to 50% of patients with a superior incision. All but two patients in the temporal-incision group had 2 D or less of postoperative astigmatism, and none had more than 3 D. In the superior incision group, astigmatism ranged up to 4 D.

“If we can bring this quality, which is comparable to phaco but at much lesser cost, then I think it will be a thing that can be used in remote areas where there are large volumes of cataract patients who are having difficulties in going to seek their services in the big cities,” Dr. Ruit said.

As part of a program to bring cataract surgery to the people who need it most, Dr. Ruit and colleagues practice what he calls social marketing to combat issues of distance, price and quality that hinder patients from accepting help.

Dr. Ruit said they use a form of payment in which operations for the poor are subsidized by operations for the wealthy. “The paying patient pays for the poor patient,” he said.

For more information:
  • Sanduk Ruit, MD, can be reached at the Tilganga Eye Center, GPO 561, Gaushala Bagmati Bridge, Kathmandu, Nepal; +977-1-449-3746; e-mail: sruit@tilganga.com.np. Ocular Surgery News was unable to determine whether Dr. Ruit has a direct financial interest in the products discussed in this article or if he is a paid consultant for any companies mentioned.
  • Indo-German surgical corporation, maker of the corrugated Simcoe cannula, can be reached at 123 Kaliandas Udyog Bhuvan, Near Century Bazar, Prabhadevi, Mumbai 400025; +91-22-2422-1809; fax: +91-22-2430-5894; e-mail: indogem@bom3.vsnl.net.in; Web site: indogerman.com.
  • Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology.