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Research Article
Research Article OpenAccess
Open Access

Corneal Incisions in Extracapsular Cataract Extraction Versus

Phacoemulsification: OCT Morphological Study
Wael A Soliman MD, Tarek A Mohamed MD* and Mohamed Sharaf Eldin MD
Department of Ophthalmology, Assiut University Hospital, Assiut, Egypt

Abstract
Aim: To evaluate clear corneal incision in manual extracapsular cataract extraction (ECCE) versus phacoemulsification
using anterior segment spectral domain optical coherence tomography (SD-OCT).
Setting: Ophthalmology department, Assiut University Hospitals, Assiut, Egypt.
Methods: This prospective study included 40 eyes of 40 subjects who had cataract surgery through a superior
clear corneal incision (20 eyes underwent manual ECCE and 20 eyes underwent phacoemulsification). Three months
postoperatively each eye was scanned at the corneal incision site using anterior segment SD-OCT. (RTVue-100;
Optovue). We compared the corneal incision in both groups considering any changes in the epithelial side; endothelial
side, and stromal healing.
Results: Perfect apposition along the epithelial side was achieved in all cases of both groups. Stepping and wound
gaping along the endothelial side was detected in 45% of the ECCE group and 10% of the phacoemulsification group.
Irregularity of the stromal healing line and double level of stromal entry were recorded in 25% and 20% of the ECCE
group respectively compared to no instances in the phacoemulsification group. We reported one incident of anterior
chamber fibrous band in growth in the ECCE group.
Conclusion: Clear corneal incision in phacoemulsification is characterized by better reproducibility, more regularity
along the stromal healing line, and better sealing at the endothelial side compared to manual ECCE corneal wound.
Both ECCE and phacoemulsification corneal incisions seal well along the epithelial side.

Keywords: Anterior segment; Cataract extraction; Clear cornea; Ex-
tracapsular; Phacoemulsification; OCT
Introduction
Although phacoemulsification through clear corneal incisions is
considered now the preferred cataract surgical technique worldwide
[1,2]. Tt is much more dependent on machinery than the conventional
manual extracapsular extraction (ECCE), and costlier. Manual ECCE
is still a popular cataract removal technique in the developing world.
Spectral domain optical coherence tomography (SD- OCT) provided
detailed cross-sectional images of structures in biological tissues with
an axial resolution of five microns and a trans-verse resolution of 15
microns. It afforded real-time, artifact-free quantitative imaging [3,4].
Although SD-OCT was designed primarily to examine the posterior
segment, imaging of the anterior segment was achieved by adjusting the
anterior module [5].
The aim of this work was to study the architecture of clear corneal
incision in manual ECCE versus phacoemulsification using anterior
segment spectral domain optical coherence tomography (SD-OCT).
were incorporated in the phacoemulsification group and 20 patients
underwent manual ECCE. All surgeries were performed by the same
surgeon.
In the phacoemulsification group, the corneal incision was
created superiorly with a 3.0 mm disposable metal keratome.
Phacoemulsification was performed utilizing the WHITESTAR
Signature® System. Stop and chop technique was used to manage the
nucleus. A foldable acrylic IOL was injected into the capsular bag
without enlargement of the clear corneal tunnel. We used only stromal
hydration to maintain apposition of the corneal incision without
suturing.
We performed ECCE through a partial thickness groove incision
(about 10 mm length) at peripheral clear cornea; the incision was made
perpendicular to tissues, approximately two-thirds thickness deep.
The anterior chamber was entered with a microsurgical knife and then
surgeon injected viscoelastic into anterior chamber. A 360- degree can-
opener anterior capsulotomy was created with a cystitome. The wound
was extended with corneoscleral scissors angling blades at 45 degrees
to tissue to create a biplanar incision. The nucleus was expressed by

Materials and Methods

We conducted this study at Assiut university hospital and EL
Noor eye center after getting the approval of the ethics committee at
the faculty of medicine. The study followed the declaration of Helsinki.
Informed consent was obtained from all patients.
This observational prospective cross-sectional study included forty
eyes of forty patients with age related cataract with no other ocular
co-morbidity (e.g. severe corneal pathology, glaucoma, inflammatory
eye disease, previous ocular trauma or surgery). None of the patients
had diabetes or other systemic disease which may affect wound healing
process. Patients were subdivided into two groups. Twenty patients
*Corresponding author: Tarek A. Mohamed, Department of Ophthalmology,
Assiut University Hospital, Assiut, Egypt, Tel: +201112049393; E-mail: atarekoph@
hotmail.com
Received: November 01, 2017; Accepted: March 05, 2018; Published: March
08, 2018
Citation: Soliman WA, Mohamed TA, Eldin MS (2018) Corneal Incisions in
Extracapsular Cataract Extraction Versus Phacoemulsification: OCT Morphological
Study. J Ocul Infect Inflamm 2: 104.
Copyright: © 2018 Soliman WA, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.

J Ocul Infect Inflamm, an open access journal Volume 2 • Issue 1 • 1000104

Citation: Soliman WA, Mohamed TA, Eldin MS (2018) Corneal Incisions in Extracapsular Cataract Extraction Versus Phacoemulsification: OCT
Morphological Study. J Ocul Infect Inflamm 2: 104.

Page 2 of 3

applying careful pressure at 6 and 12 o’clock. The cortical material was

removed with manual irrigation/aspiration. Viscoelastic was injected
into the anterior chamber and capsular bag, and then a single piece
PMMA PCIOL was implanted. The wound was carefully closed using
4-5 interrupted 10-0 nylon sutures, which were removed 2 months
postoperatively.
Anterior segment imaging was performed using SD-OCT
(RTVue-100; Optovue, Freemont, CA, USA). This device uses two
lens attachments, the corneal adaptor module (CAM) to get anterior
segment images. One of these lenses was short (CAM-S) and provided
a high-magnification view, while the other was long (CAM-L) and Figure 3: Irregular extracapsular cataract extraction clear corneal incision.
(white arrow).
provided a wider viewing angle but at a slightly decreased resolution.
In our study, we used the long attachment (CAM-L) to obtain vertical
and horizontal raster line scans 6.0-mm in length to study the center of
the incision. Image analysis was performed using the built-in analysis
program.
In the present study, SD-OCT scan was obtained three months
post-operatively to compare between the corneal incisions of the two
studied groups. We evaluated any changes along the epithelial side,
stromal healing line, and endothelial side.

Results
In this study, we examined 40 eyes of 40 patients (26 men and 14 Figure 4: Stepping at the endothelial side of extracapsular cataract extraction
women). The patients’ mean age was 52 years (ranging from 48 to 67). clear corneal incision.
Perfect wound apposition along the epithelial side was achieved in all
cases of both groups. Phacoemulsification clear corneal incision either
one-step or two-step was reported to be more coopted, smoother and
more regular (Figures 1 and 2) compared to the irregular pattern of
ECCE incision (Figure 3). Stepping and wound gaping along the
endothelial side was seen in 45% of the ECCE group and 10% of the
phacoemulsification group (Figure 4). Irregularity of the stromal

Figure 5: Double plane of entry (white arrow) and stepping (astrix) at the
endothelial side of extracapsular cataract extraction clear corneal incision.

Figure 1: One step smooth regular well coapted phacoemulsification clear

corneal incision.(white arrow).

Figure 6: Fibrous band ingrowth into the anterior chamber (white arrow) in a
case of extracapsular cataract extraction clear corneal incision.

healing line was seen in 25% of the ECCE group while was not seen
in the phacoemulsification group. Double level of stromal entry was
observed in 20% of ECCE group (Figure 5) and was not reported in the
phacoemulsification group. One case of fibrous band ingrowth into the
anterior chamber was reported in the ECCE group (Figure 6).

Discussion
Figure 2: Two steps smooth regular well coapted phacoemulsification clear
corneal incision.(white arrows). OCT imaging is a fast and precise method to study cataract surgical

J Ocul Infect Inflamm, an open access journal Volume 2 • Issue 1 • 1000104

Citation: Soliman WA, Mohamed TA, Eldin MS (2018) Corneal Incisions in Extracapsular Cataract Extraction Versus Phacoemulsification: OCT
Morphological Study. J Ocul Infect Inflamm 2: 104.
incisions. Several authors have studied clear corneal incision integrity
and healing. Most of these studies evaluated phacoemulsification
incision. In our study, we compared the corneal incision architecture
be-tween manual ECCE and phacoemulsification using OCT imaging
modality. To our knowledge, this study is the first SD-OCT report
about ECCE clear corneal incision.
Torres et al. used a retinal OCT system with adjustments to image
the cornea. They found no correlation between the structural integrity
of the phacoemulsification wound and the incision angle [6].
In 2007, the profile of phacoemulsification clear corneal cataract
incisions on the first postoperative day was examined by Fine et al. using
Zeiss Visante OCT anterior segment imaging system. They found that
the clear corneal incisions had an arcuate configuration rather than a
straight-line configuration and described stromal swelling lasting for at
least 24 hours [7]. Five architectural features of the phacoemulsification
clear corneal incisions were noted: epithelial gaping (12%), endothelial
gaping (41%), endothelial misalignment (65%), local detachment of
Descemet’s membrane (62%), and loss of coaptation (9%) [8].
In their study of clear corneal incisions, Schallhorn et al. did not
observe either external or internal wound gaping in OCT images [9].
Fine et al. found that phacoemulsification corneal wounds without
stromal hydration may develop internal gaping and incisions with
external groove (biplanar) develop both internal and external wound
gaps [7].
In our study, both groups demonstrated perfect wound apposition
along the epithelial side which might be explained by the long interval
between surgery and time of anterior segment OCT imagining.
Using Fourier-domain OCT, Teixeira et al. noted a higher
incidence of epithelial imperfection at the corneal incision site of the
wounds (36%) at first postoperative day with spontaneous resolution
on follow -up [10]. This higher incidence may be explained by very
early evaluation of the incision.
On the other hand, imperfect apposition of the endothelial
margin in the form of stepping and wound gaping was seen in 45% of
the ECCE group and only in 10% of the phacoemulsification group.
Stromal healing was perfect with no detectable irregularities in the
phacoemulsification group while irregularity of the stromal healing
line was seen in 25% of the ECCE group.
Using optical coherence tomography, internal gaping of uniplanar
incisions was reported by Torres et al. in 25% of cases at 24 hours and
10% at 1 month [6].
In their study, Peng and Liu reported gaping at the endothelial side
of the corneal phacoemulsification wound in 62.2% and gaping at the
epithelial side in 11.1% at 2 days postoperatively. 15.6% more of the
J Ocul Infect Inflamm, an open access journal
Page 3 of 3
eyes had a gap at the endothelial side at 1 week postoperatively, and
5.6% more at 1 month postoperative [11].
Conclusion
We think that the large incision length, the technique and the
multiple instruments used to create corneal incision in manual ECCE
were responsible for the difference between both groups. Surgeons
should pay attention during creation of the ECCE corneal incision to
avoid incision complications such as imperfect endothelial apposition
and irregularity of the stromal healing line which may compromise the
integrity of the incision.
The limitations of this study included the relatively small number
of cases, short follow-up period and lack of evaluation of post-operative
corneal astigmatism and its relation to OCT findings. Further studies
may be needed to address these issues.
References
1. Duffey RJ, Leaming D (2005) US trends in refractive surgery. 2004 ISRS/AAO
Survey. J Refract Surg 21: 742-748.
2. Leaming DV (2004) Practice styles and preferences of ASCRS members-2003
survey. J Cataract Refract Surg 30: 892-900.
3. Wojtkowski M, Leitgeb R, Kowalczyk A, Bajraszewski T, FercherAF (2002) In
vivo human retinal imaging by Fourier domain optical coherence tomography.
J Biomed Opt 7: 457-463.
4. Wojtkowski M, Bajraszewski T, Targowski P, Kowalczy A (2003) Real-time in
vivo imaging by high-speed spectral optical coherence tomography. Opt Lett
28: 1745-1747.
5. Sarunic MV, AsraniS, Izatt JA (2008) Imaging the ocular anterior segment
with real-time, full-range Fourier-domain optical coherence tomography. Arch
Ophthalmol 126: 537-542.
6. Torres LF, Saez-Espinola F, Colina JM, Retchkiman M, Patel MR, et al.
(2006) In vivo architectural analysis of 3.2 mm clear corneal incisions for
phacoemulsification using optical coherence tomography. J CataractRefract
Surg 32: 1820-1826.
7. Fine IH, Hoffman RS, Packer M (2007) Profile of clear corneal cataract
incisions demonstrated by ocular coherence tomography. J Cataract Refract
Surg 33: 94-97.
8. Calladine D, Packard R (2007) Clear corneal incision architecture in the
immediate postoperative period evaluated using optical coherence tomography.
J Cataract Refract Surg 33: 1429-1435.
9. Schallhorn JM, Tang M, Li Y, Song JC, Huang D (2008) Optical coherence
tomography of clear corneal incisions for cataract surgery. J Cataract Refract
Surg 34: 1561-1565.
10. Teixeira A, Salaroli C, Filho FR, Pinto FT, Souza N, et al. (2012) Architectural
analysis of clear corneal incision techniques in cataract surgery using Fourier-
domain OCT. Ophthalmic Surg Lasers Imaging 43: S103-S108.
11. Peng X, Liu Y (2013) The corneal structure change after phacoemulsification
measured by anterior segment optical coherence tomography. Sichuan Da Xue
Xue Bao Yi Xue Ban 44: 147-150.
Volume 2 • Issue 1 • 1000104