Extracapsular cataract extraction is a method of a cataract surgery that involves removing the eye's natural lens while leaving
in place the back of the capsule that holds the lens in place. The procedure requires a much smaller incision than the older procedure called intracapsular cataract extraction in which the lens and the entire capsule were removed. A modified form of extracapsular cataract extraction is called phacoemulsification and uses an even smaller incision, requiring no sutures at all. To understand the significance of ECCE, it is important to understand what a cataract is and how it interferes with vision. The eye works like a camera with two lenses. The first lens is the cornea, a clear membrane that covers the front of the eye. The second lens is the eye's natural crystalline lens, which is held in place by a capsule located behind the pupil (See Anatomy of the Eye). The cornea is responsible for about 70 percent of the eye's focusing power, while the natural lens fine-tunes the image. When the natural lens becomes cloudy, usually because of the aging process, it keeps light rays from passing through or diffuses the light in such a way that vision becomes fuzzy or hazy. This cloudy lens is called a cataract. The object of modern cataract surgery is to remove this hazy lens and to replace it with a tiny plastic prescription lens that is permanently implanted in the eye. In extracapsular cataract extraction, the surgeon makes a tiny incision in the white of the eye near the outer edge of the cornea. The size of this opening depends on whether the nucleus of the lens is to be removed all in once piece or whether it will be dissolved into tiny pieces and then vacuumed out (phacoemulsification). The surgeon then enters the eye through this incision and carefully opens the front of the capsule that holds the lens in place. After the nucleus or hard center of the lens is removed, the soft lens cortex is suctioned out, leaving the back of the capsule in place in order to strengthen and support placement of the intraocular lens. After the natural lens is removed, a prescription intraocular lens implant is placed behind the iris, where the eye's natural lens used to be. The incision through which the lens was removed requires sutures if the lens was removed in one piece. If the phacoemulsification technique is employed, sutures are usually not required to close the incision.
Intracapsular cataract extraction (ICCE) involves the removal of the lens and the surrounding lens capsule in one piece.Magnified view seen on examination with a slit lamp
Conventional extracapsular cataract extraction (ECCE): Extracapsular cataract extraction involves the removal of almost the entire natural lens while the elastic lens capsule (posterior capsule) is left intact to allow implantation of an intraocular lens. It has therefore been largely superseded and is rarely performed in countries where operating microscopes and high-technology equipment are readily available. most patients are happy with the results. Microincision cataract surgery involves a technique by which a cataract can be reached through an incision of 1.5 millimeters or less. After lens removal. an artificial plastic lens (an intraocular lens implant) can be placed in either the anterior chamber or sutured into the sulcus. Although it requires a larger incision and the use of stitches.Although glasses may still be necessary for some tasks after cataract surgery. the conventional method may be indicated for patients with very hard cataracts or other situations in which phacoemulsification is problematic.
Cataract in Human Eye. It involves manual expression of the lens through a large (usually 10–12 mm) incision made in the cornea or sclera. The procedure has a relatively high rate of complications due to the large incision required and pressure placed on the vitreous body.
a famous surgeon from India. the surgeon used a lance to push the clouded lens backward into the vitreous body of the eye. Couching is still performed by some traditional healers in Africa and parts of Asia. however. This operation. The first eye surgery performed with an operating microscope was done in Portland. Between 1948
. Daviel removed the lens through a fairly long incision in the cornea of the eye.Definition
Extracapsular cataract extraction (ECCE) is a category of eye surgery in which the lens of the eye is removed while the elastic capsule that covers the lens is left partially intact to allow implantation of an intraocular lens (IOL). there are references to.. in the same year. Cataract operations are among the oldest recorded surgical procedures. and in the treatises written around 600 B.C. and phacoemulsification. The patient's vision was corrected after intracapsular extraction by extremely thick eyeglasses or by contact lenses. a British ophthalmologist named Harold Ridley implanted the first IOL in the eye of a cataract patient. the German ophthalmologist Albrecht von Graefe refined the operation by removing the lens through a much smaller linear incision in the sclera of the eye. Oregon. an older procedure in which the surgeon removed the complete lens within its capsule and left the eye aphakic (without a lens). known as couching.
cataract surgery in the Code of Hammurabi in 1750 B. This approach is contrasted with intracapsular cataract extraction (ICCE). The two inventions that made extracapsular extraction preferable again were the operating microscope and the intraocular lens. in which the lens is removed through an incision made in the cornea or the sclera of the eye. In the ancient world. intracapsular extraction gradually became the favored method of cataract removal even though it left the patient without a lens inside the eye.
The first extracapsular extraction of a cataract was performed by a French surgeon named Jacques Daviel in 1753. in 1948.. Purpose
The purpose of ECCE is to restore clear vision by removing a clouded or discolored lens and replacing it with an IOL. was standard practice until the mid-eighteenth century. After von Graefe.C. There are two major types of ECCE: manual expression. In 1865. lenses damaged by cataracts were dislocated rather than removed in the strict sense. by Susruta. in which the lens is broken into fragments inside the capsule by ultrasound energy and removed by aspiration.
As people grow older. most cataracts are the result of the aging process. and a layer of cells between the cortex and the lens capsule known as the subcapsular epithelium. with the fibers arranged in a pattern that allows light to pass through the lens. is still widely used in developing countries with large numbers of patients with eye disorders and limited hospital budgets. Cataracts vary considerably in their speed of progression. There are three layers of cells in the lens: a central nucleus.and the 1980s.
Nuclear cataracts. It consists of protein fibers and water. Although a few people are born with cataracts or develop them in childhood. the lens is about 9 mm long and 4 mm wide.
The lens and cataract formation
To understand cataract surgery. Some people have cataracts that stop growing at an early stage of development and do not interfere with their vision. They are sometimes called brunescent cataracts because they are characterized by deposits of brown pigment that give the
. which contains cells that are metabolically active and continue to grow and divide. however. start to clump together. Although most people develop cataracts in both eyes. they do not usually progress at the same rate. In humans. they may develop in a few months or over a period of many years. and form cloudy or opaque areas in the lens. phacoemulsification is now performed more often in the United States and Europe than "standard" ECCE. which is sometimes called the crystalline lens because it is transparent. so that the person has much better vision in one eye than in the other. is located immediately behind the iris. The lens. Although phacoemulsification was first introduced in 1967. manual expression was the standard form of ECCE. it was not widely accepted at first because it requires special techniques that take time for the surgeon to learn as well as expensive specialized equipment. a cortex surrounding the nucleus. As of 2003. it is helpful to have a basic description of the structure of the lens in the human eye. which complicates their removal. It is possible for a person to have more than one type of cataract. which becomes denser and harder as a person ages. Ophthalmologists classify cataracts according to their location in the lens. Nuclear cataracts grow slowly over many years but can become very large and hard. the protein fibers in the lens become denser. The manual expression technique.
By 2020. Australia. The World Health Organization (WHO) estimated in 1997 that cataracts are responsible for 50% of cases of blindness around the world. A variety of risk factors in addition to age have been associated with cataracts. One American study found that 53. Nuclear cataracts are most commonly associated with age and with smoking as risk factors. however. It is estimated that 300. Risk factors for cortical cataracts include female sex and African or Caribbean heritage. and that between 1and 1. This type of cataract.5 million cataract extractions are performed annually in the United States. Risk factors for PSC cataracts include diabetes and a history of treatment with steroid medications. respectively. Sex. Three recent research projects carried out in the United States. with cataracts responsible for 36% of these cases of blindness. Cortical cataracts.000–400. As of 2003. that figure is expected to rise to 50 million. This frequency reflects the importance of cataracts as a major public health problem. the elderly are often under-represented in general population studies even though age is the greatest single risk factor for cataract development.2% of the general population of Africa is blind.3% of women over 60 had nuclear cataracts
lens an amber color. or 19 million people. More recent publications estimate that 1. and England. Women are slightly more likely than men to develop cataracts. Cataracts in the cortex of the lens develop more rapidly than nuclear cataracts but remain softer and are easier to remove. Posterior subcapsular (PSC) cataracts. About one person in every 50 in the general American population will eventually have to have a cataract removed. They are thought to be caused by an increase in the water content of the lens. is the softest and most rapidly growing type. Twin studies show that the identical twin of a patient with a nuclear cataract has a 48% chance of developing one. which develops between the back of the lens and the lens capsule.
Cataract extraction is one of the most frequently performed surgical procedures in industrialized countries. with the figure rising to 100% for those over 80. It is difficult. to compare the rates of cataract formation among various subgroups because present published studies use a number of different grading systems for defining and detecting cataracts. but their precise significance is debated among researchers:
Genetic factors. reported that 50% of people over the age of 60 have some degree of cataract formation. little conclusive information is available regarding the incidence of cataracts in different racial and ethnic groups in the United States. In addition.000 cases of visually disabling cataracts occur each year in the United States alone. PSC cataracts tend to scatter light at night and thus interfere with nighttime driving.
compared to 49. Studies carried out in India indicate that severe malnutrition or repeated episodes of diarrhea in childhood carry a three-to fourfold increase in risk of developing cataracts in later life. however. whether this statistic would hold true for people in other countries. no obvious biochemical or medical explanation for this correlation.7% of the men. nuclear cataracts are not related to sun exposure. Socioeconomic status (SES). A conventional extracapsular cataract extraction takes less than an hour to perform. however. and some researchers treat it with caution. Alcohol consumption. People with college or professional-school education have lower rates of cataract formation than people who did not finish high school. diarrhea.1% of the men. It is not yet known. The patient is given either a local anesthetic to numb the tissues around the eye or a topical anesthetic to numb the eye itself. People who smoke more than 25 cigarettes per day are three times as likely as nonsmokers to develop nuclear or PSC cataracts. even attempting to correct for environmental and nutritional factors. however. Cortical cataracts are more likely to develop in people with frequent exposure to sunlight. An eyelid holder is used to hold the eye open during the procedure. Use of steroid medications. Smoking. the doctor may administer a sedative intravenously.. the development of foldable acrylic IOLs has allowed many surgeons to work with incisions that are only 5–6 mm long. The ultrasound vibrations that are used in phacoemulsification tend to stress the cornea. less risky for patients with very hard cataracts or weak epithelial tissue in the cornea. PSC cataracts are known to be induced by steroids. Smoking does not appear to be related to cortical cataracts. There is. the surgeon makes an incision in the cornea at the point where the sclera and cornea meet. and malnutrition.9% of the women had cortical cataracts versus 21.. If the patient is very nervous. After the incision is made. Heavy drinking has been reported to increase the risk of developing all three types of cataracts. Diabetes. Description
Conventional extracapsular cataract extraction
Although phacoemulsification has become the preferred method of extracapsular extraction for most cataracts in the United States since the 1990s. After the area around the eye has been cleansed with antiseptic. After the anesthetic has taken effect. 25. Patients with diabetes are at increased risk of developing all three types of cataracts. Although the typical length of a standard ECCE incision was 10–12 mm in the 1970s. Exposure to ultraviolet radiation. the surgeon
. This variation is sometimes referred to as small-incision ECCE. conventional or standard ECCE is considered. Chronic dehydration. sterile drapes are used to cover most of the patient's face. even though they represent less than 10% of all cataracts.
The next step in the diagnostic examination is a test of the patient's visual acuity for both near and far distances. After the nucleus has been expressed. The specific changes in the patient's
vision depend on the type and location of the cataract. the viscoelastic substance is removed and the incision is closed with two or three stitches. the examiner will first check the intraocular pressure (IOP) and the anterior chamber of the patient's eye. the surgeon uses an ultra-sound probe inserted through the incision to break up the nucleus of the lens into smaller pieces.
In phacoemulsification. the patient may also complain of increased glare in bright daylight or glare from the headlights of oncoming cars at night. there is no pain associated with the development of cataracts.
Because visual disturbances may indicate glaucoma as well as cataracts. and a shorter recovery time for the patient. the surgeon uses suction to remove the softer cortex of the lens.makes a circular tear in the front of the lens capsule. particularly in older adults. A special viscoelastic material is injected into the empty lens capsule to help it keep its shape while the surgeon inserts the IOL.
. One study found that surgeons needed to perform about 150 cataract extractions using phacoemulsification before their complication rates fell to a baseline level. If the patient has mentioned glare. this technique is known as capsulorrhexis. In contrast to certain types of glaucoma. Its disadvantages are the need for specialized equipment and a steep learning curve for the surgeon. The surgeon then carefully opens the lens capsule and removes the hard nucleus of the lens by applying pressure with special instruments. commonly known as the Snellen test. fewer or no stitches to close the incision. The examiner will also look closely at the patient's medical history and general present physical condition for indications of diabetes or other systemic disorders that affect cataract development. What these terms mean is that the nearsighted person becomes more nearsighted while the farsighted person's near vision improves to the point that there is less need for reading glasses. in addition. Cortical and posterior subcapsular cataracts typically reduce visual acuity. The newer technique offers the advantages of a smaller incision than standard ECCE. the Snellen test will be conducted in a brightly lit room. After the intraocular lens has been placed in the correct position. Diagnosis/Preparation
The diagnosis of cataract is usually made when the patient begins to notice changes in his or her vision and consults an eye specialist. Nuclear cataracts typically produce symptoms known as myopic shift (in nearsighted patients) and second sight (in farsighted patients).
Lastly. although the operated eye will take between three weeks and three months to heal completely.
Patients can go to work the next day.The examiner will then check the patient's eyes with a slit lamp in order to evaluate the location and size of the cataract. At the end of this period. as it is likely to need adjustment. After the surgery has been scheduled. the patient will need to have special testing known as keratometry if an IOL is to be implanted. The testing. although they should have a friend or relative drive them home after the procedure. The ophthalmoscope can also be used to detect the presence of very small cataracts. The lens prescription should be checked after surgery.
ECCE is almost always elective surgery—emergency removal of a cataract is performed only when the cataract is causing glaucoma or the eye is severely injured or infected. Aftercare Patients can use their eyes after ECCE. They should wear sunglasses on
. Imaging studies of the eye (ultrasound. Patients can carry out their normal activities within one to two days of surgery. After the patient's eyes have been dilated with eye drops. the examiner will use an ophthalmoscope to evaluate the condition of the optic nerve and retina at the back of the eye. MRI. they should have their regular eyeglasses checked to see if their lens prescription should be changed. The measurements obtained by the keratometer are entered into a computer that calculates the correct power for the IOL. however. he or she will continue to need them after the IOL is implanted. If the patient was wearing eyeglasses or contact lenses before the cataract developed. The ophthalmologist will place some medications— usually steroids and antibiotics—in the operated eye before the patient leaves the office. with the exception of heavy lifting or extreme bending. The IOL is a substitute for the lens in the patient's eye. is done to determine the strength of the IOL needed. not for corrective lenses. or CT scan) may be ordered if the doctor cannot see the back of the eye because of the size and density of the cataract. which is painless. The ophthalmologist measures the length of the patient's eyeball with ultrasound and the curvature of the cornea with a device called a keratometer. Most ophthalmologists recommend that patients wear their eyeglasses during the day and tape an eye shield over the operated eye at night. the slit lamp can also be used to check the other structures of the eye for any indications of metabolic disorders or previous eye injury.
which is known as posterior capsular opacification or PCO. Risks The risks of extracapsular cataract extraction include:
Edema (swelling) of the cornea. The patient typically experiences blurring or distortion of central vision.bright days and avoid rubbing or bumping the operated eye. about 95% of patients report that their vision is substantially improved after the operation. Malpositioning of the IOL. CME rarely causes loss of sight but may take between two and 15 months to resolve completely. In the words of a British ophthalmologist "The only obstacle lying between cataract sufferers and surgical cure is resource allocation. which is a procedure in which the surgeon uses a laser to cut through the clouded part of the capsule. It is important for patients to use these eye drops exactly as directed. The macula is a small yellowish depression on the retina that may be affected after cataract surgery by fluid collecting within the tissue layers.
Patients recovering from cataract surgery will be scheduled for frequent checkups in the first few weeks following ECCE. A rise in intraocular pressure (IOP). Uveitis refers to inflammation of the layer of eye tissue that includes the iris. In addition. is not a new cataract but may still interfere with vision."
Normal results Extracapsular cataract extraction is one of the safest and most successful procedures in contemporary eye surgery. Retinal detachment or tear. Hyphema refers to the presence of blood inside the anterior chamber of the eye and is most common within the first two to three days after cataract surgery. In most cases. Infection Infection of the external eye may develop into endophthalmitis. PCO is treated by capsulotomy. This clouding. This complication can be corrected by surgery. the ophthalmologist will prescribe eye drops for one to two weeks to prevent infection. Uveitis. the ophthalmologist will check the patient's eye the day after surgery and about once a week for the next several weeks. or infection
of the interior of the eye. Hyphema. About 25% of patients who have had a cataract removed by either extracapsular method will eventually develop clouding in the lens capsule that was left in place to hold the new IOL. Cystoid macular edema (CME). Leaking or rupture of the incision. It is thought to be caused by the growth of epithelial cells left behind after the lens was removed. and reduce swelling. manage pain.
03%). and E helps to slow the rate of cataract progression.5%). on the grounds that somestudies suggest that poor nutritional
status is a risk factor for cataract. leaking from the incision (1.1%). The most common complication is swelling of the cornea (9. While vitamin supplements do not prevent cataracts. there is some evidence that an adequate intake of vitamins A. Elderly people who may be at risk of inadequate vitamin intake due to loss of appetite and other reasons may benefit from supplemental doses of these vitamins. endophthalmitis (0. C. Of these complications. however. About 23% of patients who have undergone cataract extraction have a postoperative complication. followed by raised IOP (7. In the recent past.Morbidity/Mortality Mortality as a direct result of cataract surgery is very rare.
Not all cataracts need to be removed. retinal tear (0. The majority of these.2%). only endophthalmitis and retinal detachment or tear are considered potentially vision-threatening. to have periodic checkups to make sure that the cataract is not growing in size or density. external eye infection (0. are not vision-threatening. Alternatives
As of 2003 there are no medications that can prevent or cure cataracts. and CME (0.017%). retinal detachment (0. uveitis (5. however.9%). A patient whose cataracts are not interfering with his or her normal activities and are progressing slowly may choose to postpone surgery indefinitely." which meant that the patient had to wait until the cataract
.06%). however. Standard ECCE and phacoemulsification have very similar success rates and complication rates when performed by surgeons of comparable skill and length of experience. It is important.02%). hyphema (1.03%). recommend a well-balanced diet as beneficial to the eyes as well as the rest of the body. surgeons often advised patients to put off surgical treatment until the cataract had "ripened. several studies have indicated that patients over the age of 50 who undergo cataract extraction have higher rates of mortality in the year following surgery than other patients in the same age group who
have other types of elective surgery. On the other hand. Some researchers have interpreted these data to imply that cataracts related to the aging process reflect some kind of systemic weakness rather than a disorder limited to the eye.6%). Many ophthalmologists.
which is an instrument for applying extreme cold to eye tissue. secondary glaucoma. It is then used to slowly pull the capsule and lens together through the long incision around the cornea. At present. however. the surgeon makes an incision about 150 degrees of arc. The surgeon then inserts a cryoprobe. but is still done in countries where operating microscopes and high-technology equipment are not always available. and eventual blindness. or about half the circumference of the cornea.
The major surgical alternative to ECCE is intracapsular cataract extraction. driving. In addition. The cryoprobe is placed on the lens capsule.had caused significant vision loss and was interfering with reading. In most cases. Because of the length of the incision needed to perform ICCE and the pressure placed on the vitreous body. where it freezes into place. It is rarely performed at present in Europe and North America. and most daily activities. the procedure has a relatively high rate of complications. it is up to the patient to decide when the cataract is troublesome enough to schedule surgery. ophthalmologists prefer to remove cataracts before they get to this stage because they are harder and consequently more difficult to remove. in order to extract the lens and its capsule in one piece. In addition. or ICCE. the recovery period is much longer than for standard ECCE or phacoemulsification.
. In ICCE. a rapidly growing cataract that is not treated surgically may lead to swelling of the lens.