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This study aimed to determine the incidence of posterior capsular opacity (PCO) after small incision cataract surgery in age-related cataracts and identify associated risk factors. A total of 125 eyes were followed up for 6 months post-operatively. The overall PCO incidence was 29.6%. PCO was significantly lower in patients who received continuous curvilinear capsulorhexis compared to envelope capsulotomy (22.2% vs 43.2%), and in those who underwent hydrodelineation compared to no hydrodelineation (22% vs 50%). Intraoperative complications like uveitis and iridodialysis were also associated with increased PCO risk. The study concluded that PCO

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INCIDENCE OF POSTERIOR CAPSULAR OPACITY AFTER SMALL INCISION CATARACT SURGERY IN AGE RELATED CATARACT AND THE RISK FACTORS ASSOCIATED WITH IT
INTRODUCTION  Posterior capsular opacification (PCO) is one of the most common late complications of extracapsular cataract extraction  Major cause of decreased vision after uneventful cataract surgery  More threatening in young adults and children, with a higher incidence, quicker onset and greater amblyogenic effect
INTRODUCTION  Vision impairment caused by PCO has become one of the major reasons for patients' postsurgical dissatisfaction and major ocular morbidity  It represents significant financial burden to health care system  With limited specialty service available and difficulty in follow up, measures should be taken in prevention of PCO
AIMS AND OBJECTIVES General objectives  To find out the incidence of posterior capsular opacification after small incision cataract surgery in age related cataract Specific objectives  To find out the demographic profile of patients with PCO  To find out type of cataract associated with PCO formation
AIMS AND OBJECTIVES Specific objectives:  To compare PCO in relation with type of capsulotomy - continuous curvilinear capsulorrhexis - envelop technique  To compare PCO in relation with hydrodelineation  To grade PCO after SICS in Madurai grading system
METHODOLOGY  Study Design: Prospective observational cohort study  Place of study: Department of Ophthalmology, BPKIHS, Dharan  Sample size: 125 consecutive eyes with age related cataract undergone small incision cataract surgery
Calculation of sample size: n = z2Ă—pĂ—qĂ· l2 Where n = sample size z = 1.96 at 95% confidence interval Ě´ 2 p = 15(expected result) l = 20% of p = 3 q = 85 Applying above formula n =560 According to CDC (WHO): CSS = calculated sample size 1 + calculated sample size Ă· exp. population Sample size = 112 + 10% = 125 eyes *all the samples will be included in the study.
METHODOLOGY  Period of study: one year  Follow up: 1 week, 4 week, 12 week and 6 month postoperative  Inclusion criteria: All the patients with age related cataract (more than 40 years) underwent small incision cataract surgery at BPKIHS
METHODOLOGY Exclusion criteria:  Age < 40 years  The patients undergone ICCE  Patients with anterior chamber intraocular lens  Posterior capsule rupture intraoperatively  Patient not giving consent  Patient lost to follow up  PCO present intraoperatively  Patients undergone phacoemulsification
RESULTS  All the calculations were done after completion of 6 months postoperative follow up  A total 125 eyes of 119 patients were enrolled  The mean age of the study population was 67.05 years with SD ±10.56 years
AGE AND GENDER DISTRIBUTION Age Group Gender TotalMale No (%) Female No (%) ≥40-50 years 4 5 9 (6.6%) (7.8%) (7.2%) 51-60 years 12 8 20 (19.7%) (12.5%) (16.0%) 61-70 years 27 22 49 (44.3%) (34.4%) (39.2%) 71-80 years 12 21 33 (19.7%) (32.8%) (26.4%) >80 years 6 8 14 (9.8%) (12.5%) (11.2%) Total 61 64 125 (100.0%) (100.0%) (100.0%)
DISTRIBUTION OF GENDER n=64, 51.2% n=61, 48.8% female male
HYDRODELINEATION 72.80% 27.20% Done Not done n=34 n=91
CAPSULORRHEXIS 64.80% 35.20% n=81 n=44 CCC Envelope
INCIDENCE OF PCO AFTER 6 MONTH OF CATARACT SURGERY 29.60% 70.40% n-37 n-88 PCO Presence of PCO Absence of PCO
GRADE OF POSTERIOR CAPSULE OPACIFICATION AT 6 MONTH OF CATARACT SURGERY Grades of PCO Frequency (n) Percent (%) Grade 0 88 70.4 Grade 1 18 14.4 Grade 2 17 13.6 Grade 3 2 1.6 Total 125 100.0
GRADE OF PCO AND TYPES OF CATARACT Type of cataract Grade of PCO % of PCO in types of cataract P value Grade 0 Grade 1 Grade 2 Grade 3 NS 11 3 2 0 31.25% 0.241 PSCC 13 0 2 0 13.33% MSC 8 3 5 1 52.94% NS+PSCC 29 9 7 0 35.56% NS+ PSCC+ Cortical 6 0 1 0 14.29% PSCC+ Cortical 21 3 0 1 16% Total 88 18 17 2 125
SYSTEMIC DISEASE AND PCO Systemic disease Number of cases Number of cases with PCO (percentage) P value Diabetes 38 14 (36.84%) 0.241 Hypertension 49 18(36.73%) 0.161 Atopic dermatitis 1 0(0%) 1.000* Arthritis 3 0(0%) 0.554* COPD 5 2(40%) 0.632* Thyroid disease 1 0(0%) 1.000* Heart disease 1 1(100%) 0.396*
TYPE OF CAPSULOTOMY AND PCO PCO Type of capsulotomy Total P value CCC Envelope Yes 18 19 37 0.014 22.2% 43.2% 29.6% No 63 25 88 77.8% 56.8% 70.4% Total 81 44 125 100.0% 100.0% 100.0%
PCO AND HYDRODELINEATION PCO Hydrodelineation Total P value done not done Yes 20 17 37 0.020 22.0% 50.0% 29.6% No 71 17 88 78.0% 50.0% 70.4% Total 91 34 125 100.0% 100.0% 100.0%
PCO AND POSITION OF IOL PCO position of IOL Total P Value Sulcus in the bag Yes 3 34 37 0.262 50.0% 28.6% 29.6% No 3 85 88 50.0% 71.4% 70.4% Total 6 119 125 100.0% 100.0% 100.0%
POSTOPERATIVE COMPLICATION 0 2 4 6 8 10 12 12 7 4 3 1 Corneal edema Uveitis after 1 week Hyphaema iridodialysis Raised IOP (postoperative)
INTRAOPERATIVE AND POSTOPERATIVE COMPLICATION AND PCO Complication s PCO Total P ValueYes NO Uveitis 5 2 7 0.024 Corneal edema 4 8 12 0.766 Hyphaema 3 1 4 0.077 Iridodialysis 3 0 3 0.024 Rise in IOP 1 0 1 0.296
DISCUSSION  The overall incidence of PCO was 29.4% at 6 months of follow up which is comparable to a study done by Debra et al (28% at 5 years after surgery )  Clinical grading of posterior capsular opacification was done at 6 month follow up visits in a study done in 2005 in outreach microsurgical eye clinic in Nepal, 46% of cases after manual SICS were found to develop PCO of some degree
DISCUSSION  The occurrence of PCO was significantly less in patients who had CCC capsulotomy compared to envelop technique (p= 0.014) similar to a study by Aminollah Nikeghbali ( p < 0.005)  Similarly Okihiro Nishi emphasizes that CCC can contribute to reduce PCO
DISCUSSION  In our study the occurrence PCO was significantly less in group undergoing hydrodelineation (22%) as compared to group in whom no hydrodelineation done (50%) with p value 0.02  Similar to our study, study done by Vasavada et al showed PCO was significantly lower in eyes that had multiquadrant cortical hydrodissection than in those in whom multiquadrant cortical cleaving hydrodissection not done
DISCUSSION  In our study, the incidence of PCO is more with PCIOL in ciliary sulcus (50%) than PCIOL in the bag (28.6%) (p value =0.36)  Vilhjalmsson et al found that the incidence of capsular opacification was 20% in eyes with sulcus fixation as opposed to 14% for those with capsular bag fixation
DISCUSSION  There were few intraoperative complications in our study where three cases had iridodialysis, twelve cases of corneal edema, seven cases with uveitis after 1 week, four cases with hyphaema, three cases with iridodialysis and one case with postoperative raise IOP  Similar to this study done M.Reza Dana et al showed uveitis associated with increased risk of PCO
RECOMMENDATION  Posterior capsular opacity is the second most common cause of decrease vision after cataract  can be reduced by performing simple surgical steps like - well centered continuous curvilinear capsulorrhexis, - hydrodissection enhanced cortical clean up along with hydrodelineation, and - in the bag implantation of the posterior chamber intraocular lens.
LIMITATIONS  small sample size  Short duration of follow up 6 months which is not enough to have final conclusion on incidence of PCO because Elschnig's pearl formation may takes 2-5 years to develop after cataract surgery  Cataract surgeries were conducted by many surgeons in my study so it was difficult to standardize the results
LIMITATIONS  the size of capsulorrhexis diameter was not taken into account.  The types of capsulotomy groups, continuous curvilinear capsulorrhexis and envelope technique were not equally distributed  Besides surgical techniques, role of other factors like intraocular lens materials, and designs in the formation of posterior capsular opacity could not be studied due to availability of IOL of only one material type and single design of IOL
REFERENCES  Raj S M, Vasavada A R, Kaid Johar S R VVA. Review article. Nep J OPh. 2009;1(1):43–59.  Brilliant LB, Pokhrel RP, Grasset NC, Lepkowski JM, Kolstad A, Hawks W, et al. Epidemiology of blindness in Nepal . Bull World Heal Organ. 1985;63(2):375–86.  Mark W. Epidemiology, pathophysiology, causes, morphology and visual effects of cataract. In: M Yanoff and J S Duker . Ophthalmology. third ed. Mosby Elsevier; 2009. p. 503–10.  Werner Liliana. Secondary cataract. M Yanoff and JS Duker. Ophthalmology. third ed. 2009. p. 497–502.  Pandey SK, Apple DJ, Werner L, Maloof AJ, Milverton EJ. Posterior capsule opacification: a review of the aetiopathogenesis, experimental and clinical studies and factors for prevention. Indian J Ophthalmol. Medknow Publications; 2004;52(2):99–112.
REFERENCES  Pai S, Kamath S, Kedia V, Shruthi K, Pai A. Cataract surgery in camp patients: a study on visual outcomes. Nepal J Ophthalmol. 2011 Aug 18;3(2):159–64  Raj SM, Vasavada AR, Johar SRK, Vasavada VA, Vasavada VA. Post-operative capsular opacification: a review. Int J Biomed Sci. 2007 Dec;3(4):237–50  Ebihara Y, Kato S, Oshika T, Yoshizaki M, Sugita G. Posterior capsule opacification after cataract surgery in patients with diabetes mellitus. J Cataract Refract Surg. 2006 Jul;32(7):1184–7  Vasavada AR, Dholakia SA, Raj SM, Singh R. Effect of cortical cleaving hydrodissection on posterior capsule opacification in age-related nuclear cataract. J Cataract Refract Surg. Elsevier; 2006 Jul 1;32(7):1196–200
REFERENCES  Vilhjalmsson GA, Lucas BC. [Incidence of secondary cataract in sulcus versus capsular bag fixation of posterior chamber lenses. Klin Monbl Augenheilkd. 1992 Mar;200(3):167–70  Dana MR, Chatzistefanou K, Schaumberg DA, Foster CS. Posterior Capsule Opacification after Cataract Surgery in Patients with Uveitis. Ophthalmology. 1997 Sep;104(9):1387–94.
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