This survey summarizes the current preferred cataract surgery practices among Malaysian ophthalmologists and medical officers. Most of the respondents (74%) were specialists or consultant ophthalmologists.
The pros and cons of pre-operative povidone iodine instillation to prevent endophthalmitis has been published a few years ago.(10) Malaysia post-operative endophthalmitis (POE) was reported as low as 0.08%, and this could be a result of routine instillation of povidone-iodine before cataract surgery.(11) The European Society of Cataract and Refractive Surgeons (ESCRS) recommends surgeons to instill 5-10% of povidone iodine to the cornea and conjunctival sac for at least 3 minutes to reduce postoperative endophthalmitis rate.(10) However, it is not without risk as Ridder et al reported that povidone-iodine 5% significantly decrease corneal epithelial integrity and increase subjective complaints of ocular discomfort from the patients.(12) Thus, the risk and benefit of povidone-iodine instillation have to be taken into consideration. (should add here what is the recommended practice for povidone iodine)
Topical anaesthesia plus intracameral anaesthesia remained the most popular local anaesthesia, with a marked increase from 58.8% (2011) to 83.8% (2021) (how did you get the 2011 data?). (9) This figure was similar to a Korean’s survey.(7) Subtenon anaesthesia reduced from 36.7% (2011) to 16.2% (2021). This reduction could be attributed to the reducing number of extracapsular cataract extraction (ECCE) surgeries.
New Zealand and Korean ophthalmologists have predilection over the temporal corneal incision, ranging between 57% to 71.2%. (6,7) In contrast, most of the respondents of our survey preferred fixed superior corneal incision (50.3%). Only 20.2% chose fixed temporal corneal incision. A majority (72.3%) used 2.75mm microkeratome to create the main corneal incision. New Zealand’s survey had a similar result, where 57% of them used 2.75mm to create the main wound.(6) 33.5% of respondents used microkeratome to create the paracentesis wound. This is likely to cut overall cost of the cataract surgery.
Phacoemulsification machines can be broadly divided into 2 different systems: peristaltic pump and venturi system. Each has its pros and cons with a similar safety profile in terms of risk for posterior capsular rent.(13) In this survey, the peristaltic pump was more popular (56.1%) compared to the venturi system (43.9%). There is a different approach in nucleofractis technique. The 2 main techniques were stop-chop (37%) and divide and conquer (32.9%). Phaco-chop technique was the third most common technique (23.2%).
Coaxial aspiration-irrigation was commonly used in many centres as almost all centres have such aspiration-irrigation tip. This might be the cause for its popularity among Malaysian ophthalmologists. Bimanual aspiration-irrigation has better accessibility to all areas of the capsular bag compared to the coaxial tip. (14) Otherwise, there is no significant difference in terms of posterior capsular formation among these 2 aspiration-irrigation techniques. (14)
The benefits of yellow IOLs versus clear IOLs have been extensively studied. The yellow lens can affect the perception of luminance and possibly disrupt circadian rhythm compared to clear IOL.(15,16) Most of the participants preferred clear IOL over yellow IOL. Plate haptic has better stability and has less risk for decentration and tilt compared to C-loop haptic and both of the haptic designs have a similar risk for posterior capsular opacification. (17–19) Despite plate haptic having this added advantages, C-loop haptic remained more favourable among Malaysian ophthalmologists.
Preloaded IOL delivery system has proven to shorten the surgery time and increase economic efficiency.(20) Merits of preloaded system includes prevention of IOL setting errors, potential IOL damage and elimination of variability in manual loading.(21) Double handed screw delivery system require surgeon to use both hands, single-handed push allow surgeon to use the second hand to stabilize the eye. Hence more participants preferred single-handed push preloaded system.
Prophylactic intracameral antibiotic has been proven to reduced incidence of endophthalmitis. ESCRS recommended intracameral cefuroxime injection at the end of cataract surgery.(10) Other antibiotics such as moxifloxacin and vancomycin showed similar efficacy.(22) All 3 intracameral antibiotics (cefuroxime, moxifloxacin and levofloxacin) have no safety issues when used intraocularly. (23) Probably due to the long history of safety profile of intracameral cefuroxime, it is the most popular antibiotic of choice.
Surprisingly more than a quarter of participants inject intracameral carbachol (Miostat) in their cataract surgery. There is no consensus to encourage surgeons to inject carbachol routinely during the surgery. Even though the side effect of carbachol is rare, it should be used only in selected cases. Routine usage of carbachol will increase the cost of the surgery and lengthen the surgical time, as well as reducing the theoretical risk of toxic anterior segment syndrome (TASS).