Miguel Andrei C.

Medina Cataract Surgery Pre-SGD Paper

2016-00448

1. What parts of the eye are involved in the surgery? Discuss 5.

Superior Rectus – The superior rectus is one of the extraocular muscles of the eye which
physiologically functions in elevating the eye. Placement of a bridle suture to this muscle will
help to rotate the globe downward via traction during surgery.
Conjunctiva – The conjunctiva is a structure that helps provide lubrication and protection for
the eye. A limbal-based or fornix-based conjunctival flap is made in order to create incisions
in the cornea/sclera/limbus. A conjunctival dissection is also done to deliver sub-Tenon
anesthesia.
Cornea/Sclera – The cornea is the main refractive element of the eye, and the sclera is the
fibrous outer protective coating of the eye. These are the sites of possible entry created
during cataract surgery, in order to eventually deliver the cataractous lens and insert an
intraocular lens. Besides the main incision, a side port is also made in phacoemulsification.
Anterior chamber – The anterior chamber is a chamber bordered anteriorly by the cornea
and posteriorly by the iris and pupil. We surgically navigate through the anterior chamber in
order to reach the lens.
Lens – The lens is the secondary refractive element of the eye. Through continuous
curvilinear capsulorhexis of the anterior capsule of the lens, we create the hole in order to
remove the nucleus of the lens, which may be delivered whole or phacoemulsified. We also
remove the residual cortex of the lens through aspiration.

2. What measures can be taken preoperatively in order to avoid surgical site infection?
Discuss 3.
- Treatment of preoperative infections such as blepharitis, conjunctivitis, or chronic
dacrocystitis, not only in the eye involved but also in the contralateral eye will help reduce
infections.
- The preoperative management of conditions known to increase the risk for
endophthalmitis such as entropion may also lower the risk of infection.
- Immunosuppression is a known risk factor for endophthalmitis, and ensuring that the
patient is not immunocompromised will help prevent infective complications.

3. What measures can be taken intraoperatively in order to avoid surgical site infection?
Discuss 5.
- Proper surgeon hygiene, meticulous care in donning surgical attire, and aseptic technique
should always be followed. The surgeon should also review the procedure beforehand as
surgical complications (capsular rupture/prolonged surgical time) are a risk factor for
endophthalmitis.
- Before any incisions are made, the conjunctival sac is instilled with povidone-iodine 5% and
left to work for 3 minutes to prevent infection. The surrounding skin is also cleaned. A
plastic drape and speculum also isolate the operating field from the eyelids, preventing
contamination of the operating field. It is known that the most common agents involved in
endophthalmitis originate from the patient’s eyelids.
- A scleral tunnel incision, specifically a blue-line incision, may be performed, as this carries a
significantly lower risk of infections compared to corneal tunnel incisions, due to differences
in wound healing and wound leaks. Should a corneal incision be made, it should be
watertight and self-sealing to reduce the risk of infections. It should be done in three planes
to avoid leakage. Further, longer rather than wider corneal incisions are more stable and
hence reduce the risk of leakage and endophthalmitis.
- Intraocular lenses (IOLs) with acrylic optics are less associated with infections than IOLs
with acrylic optics because of differences in the interaction of biofilms on the surface of the
lens. Further, injectable IOLs carry a reduced risk of infections compared to forceps-inserted
IOLs due to non-contact with the ocular surface, however, the manner of IOL insertion is
strongly correlated with the type and site of incision (scleral vs corneal tunnel) and it is said
that the type of incision is a more important risk factor.
- Cefuroxime 1 mg in 0.1 mL normal saline may be injected into the anterior capsule at the
end of surgery for endophthalmitis prophylaxis.

4. What measures can be taken postoperatively in order to avoid surgical site infection?
Discuss 3.

- Eye patches for at least 4 hours after surgery helps seal the wound and prevent infections.
- Topical antibiotics may also thereotically help reduce the incidence of infections, although
evidence supporting it is lacking, despite many surgeons prescribing it.
- Should a wound leak, resuture it early to reduce the risk of surgical site infections. Further,
have a post-operative consultation for patients whose surgeries were complicated, for
patients who have co-existing eye diseases, or for patients who have poor access to
healthcare.

5. Why is cataract blindness common in the Philippines? What factors hinder patients from
receiving proper treatment? Discuss 3.

- The Philippines is a low-income country and poverty is rampant. Kuper and colleagues
demonstrated an association between poor family income and visual impairment from
cataracts in three countries including the Philippines. Cost also has a part in hindering these
patients from treatment.
- Poor access to primary health care leads to many cases of cataractous eyes never even
being evaluated by a healthcare professional, however thrusts such as the DOH Vision 2020
have begun to improve access to eye care in the communities.
- Poor access to facilities which have the capabilities to perform cataract surgery
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