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. 2017 Sep 20;9(9):CD010510.
doi: 10.1002/14651858.CD010510.pub2.

Different-sized incisions for phacoemulsification in age-related cataract

Chongfei Jin  1 , Xinyi Chen, Andrew Law, Yunhee Kang, Xue Wang, Wen Xu, Ke Yao
Affiliations

Different-sized incisions for phacoemulsification in age-related cataract

Chongfei Jin et al. Cochrane Database Syst Rev. .

Abstract

Background: Age-related cataract is the principal cause of blindness and visual impairment in the world. Phacoemulsification is the main surgical procedure used to treat cataract. The comparative effectiveness and safety of different-sized incisions for phacoemulsification has not been determined.

Objectives: The aim of this systematic review was to assess the effectiveness and safety of smaller versus larger incisions for phacoemulsification in age-related cataract. The primary outcome of this review was surgically induced astigmatism at three months after surgery.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 10), MEDLINE Ovid (1946 to 28 October 2016), Embase Ovid (1947 to 28 October 2016), PubMed (1948 to 28 October 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 28 October 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com; last searched 13 May 2013), ClinicalTrials.gov (www.clinicaltrials.gov; searched 28 October 2016), and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp; searched 28 October 2016). We did not use any date or language restrictions in the electronic searches for trials.

Selection criteria: We included randomized controlled trials (RCTs) comparing different-sized incisions in people with age-related cataract undergoing phacoemulsification.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: We included 26 RCTs with a total of 2737 participants (3120 eyes). These trials were conducted in Bosnia and Herzegovina, China, France, India, Italy, Korea, Spain, Switzerland, and Turkey. Half of the 26 trials were conducted in China. We judged all trials as mostly at unclear to low risk of bias. The included RCTs compared four different-sized incisions:<= 1.5 mm, 1.8 mm, 2.2 mm, and approximately 3.0 mm. These incisions were performed using three different techniques: coaxial and biaxial microincision phacoemulsification (C-MICS and B-MICS) and standard phacoemulsification. Not all studies provided data in a form that could be included in this review. Five studies had three arms.Fifteen trials compared C-MICS (2.2 mm) with standard phacoemulsification (about 3.0 mm). Very low-certainty evidence suggested less surgically induced astigmatism in the C-MICS group at three months compared with standard phacoemulsification (mean difference (MD) -0.19 diopters (D), 95% confidence interval (CI) -0.30 to -0.09; 996 eyes; 8 RCTs). There was low-certainty evidence that both groups achieved similar best-corrected visual acuity (MD 0.00 logMAR, 95% CI -0.02 to 0.02; 242 eyes; 3 RCTs). There was low-certainty evidence of little or no difference in endothelial cell loss and central corneal thickness comparing C-MICS with standard phacoemulsification (MD -7.23 cells/mm2, 95% CI -78.66 to 64.20; 596 eyes; 4 RCTs) and (MD -0.68 μm, 95% CI -3.26 to 1.90; 487 eyes; 5 RCTs).Nine trials compared C-MICS (1.8 mm) with standard phacoemulsification (about 3.0 mm). Very low-certainty evidence suggested less astigmatism at three months in the C-MICS group compared with standard phacoemulsification group (MD -0.23 D, 95% CI -0.34 to -0.13; 561 eyes; 5 RCTs). Low-certainty evidence suggested little or no difference in best-corrected visual acuity, endothelial cell loss, and central corneal thickness in the two groups at three months (MD -0.02 logMAR, 95% CI -0.03 to -0.00; 192 eyes; 3 RCTs), (MD 7.56 cells/mm2, 95% CI -67.65 to 82.77; 380 eyes; 5 RCTs), and (MD -1.52 μm, 95% CI -6.29 to 3.25; 245 eyes; 3 RCTs).Six studies compared C-MICS (1.8 mm) with C-MICS (2.2 mm). There was low-certainty evidence that astigmatism, visual acuity, and central corneal thickness were similar in the two groups at three months (MD 0.04 D, 95% CI -0.09 to 0.16; 259 eyes; 3 RCTs), (MD 0.01 logMAR, 95% CI -0.01 to 0.04; 200 eyes; 3 RCTs), and (MD 0.45 μm, 95% CI -2.70 to 3.60; 100 eyes; 1 RCT). Very low-certainty evidence suggested higher endothelial cell loss in the 1.8 mm group (MD 213.00 cells/mm2, 95% CI 11.15 to 414.85; 70 eyes; 1 RCT).Four studies compared B-MICS (<= 1.5 mm) with standard phacoemulsification (about 3.0 mm). Astigmatism was similar in the two groups at three months (MD -0.01 D, 95% CI -0.03 to 0.01; 368 eyes; 2 RCTs; moderate-certainty evidence). There was low-certainty evidence on visual acuity, suggesting little or no difference between the two groups (MD -0.02 logMAR, 95% CI -0.04 to -0.00; 464 eyes; 3 RCTs). Low-certainty evidence on endothelial cell loss and central corneal thickness also suggested little or no difference between the two groups (MD 55.83 cells/mm2, 95% CI -34.93 to 146.59; 280 eyes; 1 RCT) and (MD 0.10 μm, 95% CI -14.04 to 14.24; 90 eyes; 1 RCT).None of the trials reported on quality of life. One trial reported that no participants experienced endophthalmitis or posterior capsule rupture; they also reported little or no difference between incision groups regarding corneal edema (risk ratio 1.02, 95% CI 0.40 to 2.63; 362 eyes).

Authors' conclusions: Phacoemulsification with smaller incisions was not consistently associated with less surgically induced astigmatism compared with phacoemulsification with larger incisions. Coaxial microincision phacoemulsification may be associated with less astigmatism than standard phacoemulsification, but the difference was small, in the order of 0.2 D, and the evidence was uncertain. Safety outcomes and quality of life were not adequately reported; these should be addressed in future studies.

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Conflict of interest statement

Chongfei Jin: is a coauthor of an included study (Yao 2011) Xinyi Chen: no conflicts of interest Andrew Law: no conflicts of interest Yunhee Kang: no conflicts of interest Xue Wang: no conflicts of interest Wen Xu: no conflicts of interest Ke Yao: is a coauthor of three included studies (Yao 2008; Yao 2011; Yu 2016)

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 1 Mean postoperative surgically induced astigmatism at 3 months.
1.2
1.2. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 2 Mean postoperative best‐corrected visual acuity at 3 months.
1.3
1.3. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 3 Mean change of endothelial cell loss at 3 months.
1.4
1.4. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 4 Mean change of central corneal thickness at 3 months.
1.5
1.5. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 5 Intraoperative use of cumulative dissipated energy.
1.6
1.6. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 6 Intraoperative use of balanced salt solution.
1.7
1.7. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 7 Surgical time.
1.8
1.8. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 8 Phacoemulsification time.
1.9
1.9. Analysis
Comparison 1 Larger coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 9 Corneal edema.
2.1
2.1. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 1 Mean postoperative surgically induced astigmatism at 3 months.
2.2
2.2. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 2 Mean postoperative best‐corrected visual acuity at 3 months.
2.3
2.3. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 3 Mean change of endothelial cell loss at 3 months.
2.4
2.4. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 4 Mean change of central corneal thickness at 3 months.
2.5
2.5. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 5 Intraoperative use of cumulative dissipated energy.
2.6
2.6. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 6 Intraoperative use of balanced salt solution.
2.7
2.7. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 7 Surgical time.
2.8
2.8. Analysis
Comparison 2 Smaller coaxial microincision cataract surgery versus standard phacoemulsification, Outcome 8 Phacoemulsification time.
3.1
3.1. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 1 Mean postoperative surgically induced astigmatism at 3 months.
3.2
3.2. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 2 Mean postoperative best‐corrected visual acuity at 3 months.
3.3
3.3. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 3 Mean endothelial cell loss at 3 months.
3.4
3.4. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 4 Mean change of central corneal thickness at 3 months.
3.5
3.5. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 5 Intraoperative use of cumulative dissipated energy.
3.6
3.6. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 6 Intraoperative use of balanced salt solution.
3.7
3.7. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 7 Surgical time.
3.8
3.8. Analysis
Comparison 3 Smaller versus larger coaxial microincision cataract surgery, Outcome 8 Phacoemulsification time.
4.1
4.1. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 1 Mean postoperative surgically induced astigmatism at 3 months.
4.2
4.2. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 2 Mean postoperative surgically induced astigmatism at 6 months.
4.3
4.3. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 3 Mean postoperative best‐corrected visual acuity at 3 months.
4.4
4.4. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 4 Mean endothelial cell loss at 3 months.
4.5
4.5. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 5 Postoperative central corneal thickness at 3 months.
4.6
4.6. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 6 Intraoperative use of cumulative dissipated energy.
4.7
4.7. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 7 Surgical time.
4.8
4.8. Analysis
Comparison 4 Biaxial microincision cataract surgery versus standard phacoemulsification, Outcome 8 Phacoemulsification time.
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References

References to studies included in this review

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Alio 2005 {published data only}
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