We would like to congratulate Dr. Muralidhar and his colleagues for the study on a subject which is an established clinical practice at least in developing countries, but has never been well documented. Results of this study are of great value for ophthalmologists in developing countries like India where care and cost of care has to be finely balanced.
In their non-randomized observational study, Muralidhar et al., found that the completion rate of anteriorcontinuouscurvilinear capsulorrhexis by trainee surgeons with the use of 2% hydroxypropylmethycellulose was 66.7% and overall completion rate with the help of a senior surgeon was 81.8%. This is acceptable as compared to 90% completion rate with use of Healon in studies by Jeng et al. Again, Hamada et al., reported a completion rate of anterior and posterior capsulorrhexis of 100% with use of Healon GV. The completion rates of posterior capsulorrhexis reported by the authors in their study was 90%, which is fairly comparable.
We feel that the authors have not factored in two variables which may change the outcomes in a similar study. These two factors are the age of the patient and the experience of the surgeon. Majority of the patients in their study group are 2 years or older except one patient. Only 1 child who is under 2 years had an extension of the anterior rhexis. Cataract surgery in younger children often is more challenging in view of higher positive vitreous pressure and shallower anterior chambers. With the publication of Infant Aphakia Treatment Study results, more children younger than two years are likely to undergo primary intraocular lens (IOL) implantation. We genuinely feel that this study could have been more valuable and complete had the authors included more children less than 2 years of age. We also feel that completion rates will be lower in younger children with use of low cost viscoelastics.
We agree with the authors in their conclusion, that the completion rates are expected to be better for experienced surgeons. It would have been helpful if they had compared completion rates of experienced surgeon to that of trainees in age matched controls.
In addition, the authors have not included cataracts with anterior segment anomalies like zonular weakness, fibrotic capsules, capsular plaques, persistent hyperplastic primary vitreous etc., in their study. Further studies are needed to assess completion rates with low cost viscoelastic in these admittedly difficult cases.
1. Muralidhar R, Siddalinga Swamy GS, Vijayalakshmi P. Completion rates of anterior and posterior continuous curvilinear capsulorrhexis in pediatric cataract surgery for surgery performed by trainee surgeons with the use of a low cost viscoelastic Indian J Ophthalmol. 2012;60:144–6
2. Jeng BH, Hoyt CS, McLeod SD. Completion rate of CCC in pediatric surgery using different viscoelastic materials J Cataract Refract Surg. 2004;30:85–8
3. Hamada S, Low S, Walters BC, Nischal KK. Five year experience of the TIPP technique for anterior and posterior rhexis in pediatric cataract surgery Ophthalmology. 2006;113:1309–14
4. Wilson ME, Pandey SK, Werner LAgarwal S, Agarwal A, Apple DJ, Buratto L, Alio J, Pandey SK. Pediatric Cataract Surgery: Current Techniques, Complications and Management Textbook of Ophthalmology. 2002 New Delhi, India:1861–79
5. Lambert SR, Buckley EG, Drews-Botsch C, DuBois L, Hartmann EE, Lynn MJ, et alThe Infant Aphakia Treatment Study Group. A randomized clinical trial comparing contact lens with intraocular lens correction of monocular aphakia during infancy Arch Ophthalmol. 2010;128:810–8