MEAN INTRAOCULAR PRESSURE AFTER PHACOEMULSIFICATION USING 2 %

HYDROXYPROPYL METHYLCELLULOSEAND 1 % SODIUM HYALURONATEAS

VISCOELASTICS

Introduction
The development of new surgical phaco techniques is aimed at restoring visual acuity (VA) in
order to secure a fast return to normal social life and work.Small incision phaco procedures have
minimized postoperative astigmatism.1

Application of viscoelastic substances has improved quality of anterior chamber surgery. The
first use of viscoelastic agents in cataract surgery will be described in 1972 by Balazet
al.2Viscoelastics, or ophthalmic viscosurgical devices (OVDs), facilitate cataract surgery by
maintaining the depth and shape of the anterior chamber. This provides a workspace for the
surgeon and provides a viscous barrier that protects the delicate corneal endothelium from
surgical instruments, from cataractous lens debris, and from the intraocular lens & injector
during insertion.3

An ideal viscoelastic substance possess certain important rheological properties like viscosity,
elasticity and pseudoplasticity. Viscosity makes a material protective and lubricating, while
elasticity provides protection from vibration and other mechanical impacts.Pseudoplasticity
causes the material to deform which allows safe manipulation of tissues. An ideal viscoelastic
substance must be sterile, optically clear, non-inflammatory, dilutable, hydrophilic and
biologically inert.4

Early OVDS will be classified as either cohesive or dispersive, on the basis of objective
rheological properties5.A cohesive hyaluronate OVD with high molecular weight, such as
Healon, contains long polysaccaride chains with glycosidic connections, which gives it higher
viscosity, pseudoplasticity and cohesiveness. Cohesive OVDs are good at maintaining space and
stabilizing tissue during surgery. They are easy to inject and to remove from the anterior
1
chamber .Dispersive viscoelastic substances like 2% HPMC has lower viscosity with short
molecular chains that have less tendency to entangle. They have better adherence to the corneal
endothelium against fluid during phacoemulsification.4

The major complication of viscoelastic material usage is a risk of increase intraocular pressure
within first 24 hours after cataract surgery.Leaving a significant amount of an agent in the
anterior chamber with obstruction to the outflow of aqueous humor from the anterior chamber
may cause intraocular pressure rise. This may be due to mechanical obstruction of trabecular
meshwork or functional or structional damage of trabecular meshwork.2
The rise in intraocular pressure most commonly occur between 4-7 hours post-operatively and
often returns to normal within 24-48 hours. 4 Residual OVD left in the eye can clog the trabecular
meshwork, leading to a transient elevation in postoperative intraocular pressure.5

There will be no significant difference in the pre-operative intraocular pressure between the two
groups (p=0.483). Twenty four hours after surgery, the mean IOP increased by 2.84SD 2.12 mm
Hg in 2% Hydroxypropyl Methylcellulose group and 4.542.07 mm Hg in 1% Sodium H
yaluronate group. The increase will be significantly higher in 1% Sodium Hyaluronate group as
compared to 2% Hydroxypropyl Methylcellulose group(p=0.003). Seven days after surgery the
mean intraocular pressure returned to near pre-operative levels in both the groups.6
.
The rationale of this study will be to evaluate the short term effect of these two different
viscoelastics on post operative intraocular pressure.Due to the great variation of result between
national and international studies this study will help us in generation of our own data regarding
post operative IOP using different viscoelastics and will influence our management towards
patients in future as regard to the preference of one particular type of viscoelastic.

OBJECTIVE OF THE STUDY:

The objective of the study will be to

To compare mean intraocular pressure rise after phacoemulsification with implantation of

intraocular lens using 2% HPMC and 1% NaHa as viscoelastics.

HYPOTHESIS:

Use of sodiumhyaluronate causes higher rise of IOP as compared to hydroxypropyl

methylcellulose when used as as viscoelastic in phacoemulsification.

OPERATIONAL DEFINITION:

Intraocular pressure(IOP):It is the pressure of the inside of the eyeball.Normal value is

between 11-21 mm of Hg as measured by Goldmann applanation tonometry

Cataract: It is defined as a condition in which some or all lens fibers are opacified.

Viscoelastics:
Viscoelastics are biopolymers whose main constituents are glycosaminoglycans and
hydroypropyl methylcellulose. All have the propensity to cause raised intraocular pressure until
removed carefully at the end of surgery. Main types are

Cohesive:

Long chain and high molecular weight

Easy to remove
Used to create and maintain intraocular spaces, e.g to maintain the anterior chamber
during capsulorhexis and inflation of the capsular bag to facilitate introduction of
intraocular lens.
In our study cohesive viscoelastic used is NaHa1%

Dispersive:

Low molecular weight and a tendency to break up

Used to coat and protect endothelium
Can also be used to maintain and create space
More difficult to remove than cohesive viscoelastics.
In our study dispersive viscoelastic used is 2%HPMC.

MATERIALS AND METHODS:

STUDY DESIGN:Randomized control trial

SETTING:Eye Ward, Hayatabad Medical Complex (HMC) Peshawar.

DURATION:Minimum 6 months after approval of synopsis

SAMPLE SIZE:

SAMPLING TECHNIQUE: Convenience Non-probability sampling

SAMPLE SELECTION:

INCLUSION CRITERIA:

Normal preoperative intraocular pressure(IOP)-11mm Hg -21mm Hg

Immature senile cataract
Age 45-70years
Gonioscopically open angle(Shaffers Grade III & IV)
ARC
EXCLUSION CRITERIA:
History of previous intraocular surgery
Glaucoma
 Intraocular inflammation, Complicated cataract
Diabetes mellitus
Hypertension
Tv cararact

JUSTIFICATION:

The above mentioned conditions will act as confounders and will introduce bias in the study
results.

DATA COLLECTION PROCEDURE:

After getting approval from the hospital committee to conduct the study, all those patients who
would be admitted for phacoemulsification with implantation of IOL as per indication of senile
immature cataract through OPD to Eye A Ward will be evaluated.Before evaluation all the
patients will be provided with complete information about the study and informed written
consent will be taken from each.A detailed slit lamp examination will be performed in all these
patients to look for any signs of intraocular inflammation or evidence of previous intraocular
surgery.Gonioscopy and fundus examination will be done for glaucoma. All patients will be
informed about the study and informed written consent will be obtained. Those who fits the
inclusion criteria will then randomlyallocated into 2 groups.One group will be receiving 1%
sodium hyaluronate as viscoelastic while the group 2% hydroxymethylcellulose as viscoelastic.A
comprehensive proforma is devised to record patients particulars.All the surgeries will be done
by a single ophthalmologist. intraocular pressure will also be measured by the same
ophthalmologist 1 day prior to surgery , then 1 day post operative using Goldman Applanation
Tonometer and no pressure lowering drug will be used during this time.

DATA ANALYSIS PROCEDURE:

All the data will be collected and analyzed by SPSS version 12 for windows.Student t test will be
use to compare the mean IOP of each group at each time interval.t test will also be applied for
comparison of results between the two groups.A p value of < 0.05 will be use as significance cut
off point.For gender male to female ratio will also be calculated.The results obtained will be
presented through tables,charts & graphs.

REFERNCES:
1)Paulsen AS, Norreguard JS, Farik G, Tarnhoj J. The influence of viscoelastic substances on the
corneal endothelial cell population during cataract surgery:a prospective study of cohesive and
adhesive viscoelastics.ActaOphthalmologica Scandinavica.2010;85(2):183-7

2)Javadzadeh AR,EsmaeeliKH.Intraocular pressure after small incision cataract surgery with two
different viscoelastic agents.Med J Islamic AcaSci.2009;16(2):87-91.

3) Modi SS, Davidson AJ, WaltersT.Safety ,efficacy and intraoperative characteristics of

Discovisc and Healonophthalmicviscosurgical devices for cataractsurgery. Clin
Ophthalmol.2011;5:1381-9

4)Will beeem M, Rustam N, IslamQU.Intraocular pressure after phacoemulsification using

hydroxypropyl methylcellulose and sodium hyluronate as viscoelastics.JAyub Medical Coll
Abbottabad.2011;19(1)

5)Arshinoff SA, Jafari M. New classification of ophthalmic viscosurgical devices2005. J

Cataract Refract Surg. 2012;31(11):21672171.

6.Muhammad Will beeem, Naeem Rustam, Qamar ul Islam, intraocular pressure after
phacoemulsification using hydroxypropyl methylcellulose and sodium hyaluronate as
viscoelastics; J Ayub Med Coll Abbottabad 2007; 19(1)42-5

TO DETERMINE INTRAOCULAR PRESSURE ON FIRST POST OPERATIVE DAY

AFTER PHACOEMULSIFICATION USING TWO DIFFERENT VISCOELASTICS I-E 2
% HYDROXYPROPYL METHYLCELLULOSE AND 1 % SODIUM HYALURONATE
 PROFORMA

NAME: _______________________________

Father name: __________________________

Age: _______

Gender: _____

Date of admission:

Admission No:

Group: 2% HPMC/ 1% SODIUM HYLUTONATE:

1 day pre operative intraocular pressure:

1 day post operative intraocular pressure: