Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : March | Volume : 17 | Issue : 3 | Page : NC04 - NC08 Full Version

Comparative Study of Surgically Induced Astigmatism in Manual Small Incision Cataract Surgery


Published: March 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/61713.17604
Dnyanoba Mukund Darade, Jayshri Hariharrao Pendamkar, Bhagyashree Suresh Wangikar

1. Associate Professor, Department of Ophthalmology, Byramjee Jeejobhoy Government Medical College, Pune, Maharashtra, India. 2. Resident, Department of Ophthalmology, Byramjee Jeejobhoy Government Medical College, Pune, Maharashtra, India. 3. Resident, Department of Ophthalmology, Byramjee Jeejobhoy Government Medical College, Pune, Maharashtra, India.

Correspondence Address :
Dr. Jayshri Hariharrao Pendamkar,
Resident, Department of Ophthalmology, Byramjee Jeejobhoy Government Medical College, Pune, Maharashtra, India.
E-mail: jayshripendamkar5591@gmail.com

Abstract

Introduction: Various types of incisions have been adopted and applied in Manual Small Incision Cataract Surgery (MSICS) with the primary objective to attain minimum postoperative Surgically Induced Astigmatism (SIA).

Aim: To evaluate and compare the postoperative visual acuity and to determine SIA in Batwing incision and Frown incision in MSICS.

Materials and Methods: The present study was a prospective, cross-sectional, interventional, comparative descriptive study in which a total of 380 patients aged 40 years and above with senile, uncomplicated cataract, undergoing MSICS were included. Patients were randomly divided into: Group B (Batwing incision), and Group F (Frown incision). Patients were compared on 6th week postoperatively for Uncorrected Visual Acuity (UCVA), Best Corrected Visual Acuity (BCVA) and SIA (performed using SIA Calculator Version 2.1). The data was collected in terms of demographic, clinical and biochemical characteristics that were expressed as range, mean and median and subjected to statistical analysis to obtain results.

Results: In group F, total 04 (2.11%) patients showed no astigmatism, 115 (60.53%) patients showed 0-0.5D of SIA, 64 (33.68%) were seen with 0.5-1D of SIA and 07 (3.68%) patients with 1-1.5 D SIA, no patient showed SIA more than 1.5 D. In Group B 01 (0.52%) patient showed no SIA, in 61 (32.11%) 0-0.5D of SIA was seen, in 79 (41.58%) patients 0.5-1D of SIA was seen and 45 (23.68%) patients had presented with 1-1.5D of SIA while 04 (2.11%) patients with more than 1.5D of SIA. In group F, average preoperative astigmatism preoperatively was 0.55±0.36D and average astigmatism at six weeks postoperatively was 0.46±0.33D. In Group B, average preoperative astigmatism was 0.49±0.39D and average astigmatism six weeks postoperatively was 0.54±0.40D.

Conclusion: The present study showed the superiority of Frown incision over Batwing incision in terms of less SIA and improved postoperative unaided visual results.

Keywords

Best corrected visual acuity, Batwing incision, Cataract, Frown incision

According to World Health Organisation (WHO), 19.34 million people are bilaterally blind due to senile cataract accounting for 43% of all blindness (1),(2). The number of people affected due to cataract (leading cause of blindness) in India is approximately 3.8 million people who become blind as was reported by Minassian DC and Mehra V (3). In developing countries like India, blindness due to cataract appears to be one of the biggest issues, with respect to human morbidity, financial forfeiture and social problem. One of the most common surgical procedures that is performed in ophthalmology is that of cataract surgery which is regarded as the most economical surgical intervention with respect to enhancement of the quality of life of an individual (4),(5).

The universally accepted standard surgery for cataract is phacoemulsification which is often available to those patients who can furtively afford it. Phacoemulsification entails a substantial investment when compared to manual Extracapsular Cataract Surgery (ECCE). Few of the other disadvantages of this method includes availability of technical support, longer learning period for new cataract surgeons to excel and the presence of advanced mature cataracts that are more challenging to remove with phacoemulsification along with higher complication rate (6).

Hence, to overcome such challenges of phacoemulsification, substitute cataract surgical techniques such as the MSICS have become widely accepted and popular in the developing countries. MSICS produces brilliant results at a lesser expense and approximately less surgical time than phacoemulsification and ECCE. This technique is easy to learn and also is safer for advanced mature cataracts and has become a popular and widely accepted technique for cataract surgery in India (6). Some of the advantages of MSICS includes shorter time span, less expensive, less dependent on, easy to learn and adapt, requires minimal instrumentation, can be performed in all settings and less chances of posterior segment complications like nucleus drop, posterior capsular rent etc., (7). Additionally, scleral incision wound delivers better healing, early wound stability, visual rehabilitation, reduced postoperative wound infection and endophthalmitis and no suture-related complications in suture-less MSICS (8).

The prospect of enhanced visual outcome following cataract surgery necessitates the surgeons to curtail postoperative refractive error or SIA. The correction of spherical error is attained by selecting the accurate power of Intraocular Lens (IOL) depending on the determination of exact axial length and corneal power. Corneal astigmatism being another refractive error should be managed and minimised in order to attain postoperative emmetropia. The patient needs <0.50D of astigmatism after surgery to acquire true spectacle independence (9). There are several type of incisions that are being adopted in MSICS with the aim to keep minimum postoperative astigmatism. It is established that all scleral incisions provide benefits of early healing, faster visual restoration and astigmatism control (10).

Hence, the present study was conducted to evaluate and compare the postoperative visual acuity and to determine SIA in Batwing incision and Frown incision in MSICS. The study also focuses to compare better incision in view of less SIA and better visual outcome.

Material and Methods

The present prospective, cross-sectional, interventional, comparative descriptive study was conducted in Department of Ophthalmology at a Tertiary Care Hospital, BJGMC and Sassoon General Hospital, Pune, Maharashtra, India. The study protocol was approved by the Institutional Ethics Committee (IEC) with IEC number 1119236-236. The study was conducted from August 2019 till January 2021 (18 months period). The study sample included patients who were diagnosed with cataract were selected from the outpatient department of tertiary care hospital and informed consent was obtained from them. Lens opacity for the patients was graded according to the Lens Opacity Classification System III (LOCSIII).

Inclusion criteria:

• Patient with senile uncomplicated cataract aged 40 years and above;
• Nuclear sclerosis grade 1 to grade 4;
• Patients with no other cause of defective vision other than cataract;
• Patients with no history of previous ocular surgery in operating eye.

Exclusion criteria:

• Patients with posterior segment pathology;
• Patients with other ocular pathology including complicated cataract;
• Patients with intraoperative complications (Nucleus drop, posterior capsular rent);
• Cases with premature entry;
• Cases where valve could not be formed properly either due to deep or superficial incision;
• Cases in which suture has been applied.

Sample size calculation: The sample size was calculated using the formulae:

N=Z2×P×(1-P)/d2;

Where; Z was statistic for a level of confidence (here Z=1.96 at 95% confidence interval) and P=was prevalence (in proportion of one). In the present study, prevalence of cataract among population above 40 years taken as 0.54%; d=precision (in the present study it was taken as 5%) and therefore, the final sample size for the present study was={(1.96)2×0.54×0.46]/(0.05)2=380. These 380 patients aged 40 years and above with senile, uncomplicated cataract, undergoing MSICS with PCIOL implantation were included in the sample of the study.

Study Procedure

Patients were divided in two groups, Group B receiving Batwing incision, and Group F´ receiving Frown incision. Patients were compared on 6th week postoperatively for UCVA, BCVA and SIA. All calculations for SIA were performed using SIA calculator Version 2.1. On the day of surgery the pupil was dilated with eyedrop Tropicamide 0.8%+ Phenylephrine 5%. Peribulbar anaesthesia was given and after making fornix based conjunctival flap, scleral incision was made with: a) Batwing Incision: 6-6.25 mm in size, 2 mm behind the limbus (4-4.25 mm straight incision with 1 mm wing on each end); and b) Frown Incision: 6-6.25 mm in size, 2 mm behind the limbus. These were self-sealing tunnel, and hence no sutures were applied.

Preoperative assessment was done in terms of visual acuity, K1/K2, Type of astigmatism i.e., with the rule/against the rule/no astigmatism. Postoperative assessment was also done using visual acuity, K1/K2 and Type of astigmatism i.e., with the rule/against the rule/no astigmatism.

Statistical Analysis

Detailed clinical history, proper general/systemic/ocular examination, Visual acuity using Snellen charts, LogMAR chart and Astigmatism Double Angle Plot Tool V132 have been used for vector analysis in the present study. The data was collected in terms of demographic, clinical and biochemical characteristics that were expressed as range, mean and median and were tabulated and subjected to statistical analysis to obtain the final results. SIA Calculator version 2.1 Software programme, IBM SPSS version 20.0 and 2022GraphPad Software was used for analysis of the data.

Results

The age group included in study ranged between 50-88 years with the mean age of 69 years. A total of 185 males and 195 females were included in the study. Among the male patients, 89 received Frown incision (Group F) and 96 received Batwing incision (Group B) whereas among the females, 101 patients received Frown incision and 94 received Batwing incision. In group F, among 110 patients the right eye was operated and 80 patients the left eye was operated, while in Batwing incision group in 105 patients the right eye and in 85 patients the left eye was operated. Out of total study subjects, 215 (56.6%) were operated for right eye and 165 (43.4%) were operated for left eye. Out of total study subjects, 206 (54.2%) were operated for right eye and 174 (45.8%) were operated for left eye.

(Table/Fig 1) depicts the amount of SIA at six weeks postoperative period.

While comparing between the two groups, the magnitude of SIA was found to be more in Batwing incision as compared to Frown incision (Table/Fig 2). In Frown incision group, average preoperative astigmatism preoperatively was 0.55±0.36D and average astigmatism at six weeks postoperatively was 0.46±0.33D. In Batwing incision group, average preoperative astigmatism was 0.49±0.39D and average astigmatism six weeks postoperatively was 0.54±0.40D.

(Table/Fig 3) shows the mean preoperative SIA and postoperative astigmatism. Mean SIA was less in Frown incision group (0.40 D at 82°) as compared to Batwing incision group (0.71D at 80°), showing with the rule astigmatism shift. (Table/Fig 4) shows the types of astigmatism in preoperative and at six weeks postoperatively in both the groups.

The data has been depicted in vector analysis double angle plots to enlighten the scenario more (Table/Fig 5),(Table/Fig 6).

The SIA vectors in the frown incision group on the DAP (Table/Fig 5) in preoperative scenario showed more clustering near horizontal axis directing towards ATR astigmatism in maximum samples, while at postoperative six weeks its showing clustering implying a high predictive value of the centroid obtained. This indicates that making a superotemporal tunnel consistently induced shift of astigmatism towards ‘With The Rule (WTR)’, this is because the superotemporal tunnel causes more flattening of horizontal meridian and steepening of vertical meridian to WTR shift. This may be advantageous as most of the elderly patients who have ‘Against The Rule (ATR)’ astigmatism (80).

The SIA vectors in the Batwing incision group on the DAP (Table/Fig 6) in preoperative cases showed more clustering near horizontal axis directing towards ATR astigmatism in maximum samples, while at postoperative six weeks its showing clustering implying a high predictive value of the centroid obtained. This indicates shift astigmatism towards WTR, because of flattening of horizontal meridian and steepening of vertical meridian (80).

(Table/Fig 7) shows comparison of preoperative and postoperative UCVA, the postoperative visual outcome was better in group F (Frown incision group). On ‘paired t- test’ p-value for preoperative UCVA was 0.164 (statistically insignificant) and for postoperative UCVA (<0.0001) was extremely statistically significant (Table/Fig 8). (Table/Fig 9) shows the comparison of BCVA preoperative and postoperative in both groups with LogMAR visual acuity charts. BCVA shows preoperative and postoperative values statistically insignificant with p-value 0.116 and 0.139, respectively (Table/Fig 10).

Discussion

Although phacoemulsification has proven to be advantageous for cataract surgeries, owing to the economic and technical reasons the procedure is limited to big cities and institutions only. Non phaco or MSICS by feature of its self-sealing suture-less incision appears as a brilliant option for managing the cataract burden in developing countries and hence MSICS with its cheaper cost serves to be beneficial. A variety of scleral incisions are being used in MSICS so as to keep minimum postoperative astigmatism. All scleral pocket incisions have the advantages of intra and postoperative stability including early healing, faster visual restoration and superior astigmatism control (7).

Almost any spherical refractive error can be corrected by replacing the crystalline lens with an intraocular lens. Work requiring stereopsis and good visual acuity may therefore become impossible. Many forms of surgery have the potential to affect refraction to some degree by causing one or more of these changes. A greater understanding of the effects of ocular incisions and suture placement on corneal astigmatism has done much to reduce inconvenient postoperative refractive errors. Patients who are selected for cataract surgery are anticipated to have a clear vision and less dependence on spectacles. Thus, to achieve this goal, SIA has to be reduced. Modern cataract surgery aims at this modification. In the present study, astigmatism was assessed by using keratometry readings and SIA was calculated with SIA Soft Microsoft excel sheet calculator. The change in the corneal curvature is responsible for SIA and the astigmatic refractive error. Uncorrected astigmatism that is usually caused due to the length of incision and site, can cause blurred images and glare that could produce patient distress and displeasure with otherwise uneventful cataract surgery (11),(12).

The mean age of the study participants in the present study was 69 years (range 55-88 years) which was in correlation with previous studies that proves cataract to be a condition occurring in people in their fifth decades of life and beyond (13),(14). Out of total study subjects, 206 (54.2%) were operated for the right eye and 174 (45.8%) were operated for the left eye. In Frown incision group, 110 patients were operated for the right eye and 80 patients for the left eye while in Batwing incision group in 105 patients the right eye was operated and in 85 patients the left eye was operated. Amplitude of SIA among two groups was found to be more in Batwing incision as compared to Frown incision. SIA Amplitude (Mean±SD) at six weeks postoperative in Frown incision group was 0.47±0.27 at 84 degree. Masket S et al., conducted a study on cataract extraction with frown incision observed that the average postoperative induced astigmatism of 0.5D at six weeks (15). The study conducted in 2005 by Gokhale NS and Sawhney S showed that the amplitude of SIA in superotemporal frown incision group was 0.51+0.49 D (16). These studies are congruent to the results of the present study. Gokhale NS and Sawhney S reported the mean astigmatism in manual SICS with frown incision to be 1.28 D at 29 degrees whereas the present study showed less SIA which was found to be in contrast (16). Amplitude of SIA postoperatively in Group B after six weeks was 0.80±0.39 D at 80 degrees for Batwing incision implying minimal SIA.

For analysing the net type of corneal astigmatism, keratometry readings were taken pre- and postoperatively which indicated that making a superotemporal tunnel consistently induced shift of astigmatism towards WTR, this is because the superotemporal tunnel causes flattening of horizontal meridian and steepening of vertical meridian to WTR shift. This may be advantageous as most of the elderly patients have ATR astigmatism (16). The study conducted in rural south area by Hoovayya KS and Kumar A showed that ATR is the commonest type of astigmatism in patients undergoing cataract surgery (17). Similar results were also shown by Gokhale NS and Sawhney S; Yadav HR and Rai VG; and Jaffe NS et al., which were found to be in concordance to the present study results (16),(18),(19).

On comparing pre- and postoperative UCVA the postoperative visual outcome was better in group F which showed 6/12 and better UCVA in 98.9% cases which was found to be similar to the study done by Gurung A et al., (20). The present study depicted postoperative BCVA 6/6 in 94.21% (179) patients of Frown incision; and in 92.63% (176) in Batwing incision group by Snellen’s visual acuity chart. In the current study, all the patients were seen with UCVA and BCVA better than and equal to 6/18 at six weeks postoperative which was in agreement to the study done by Rohatgi J et al., who found 93.3% of patients had BCVA of 6/18 or better at eight week after SICS with central frown incision (21). The study results confirmed the superiority of Frown incision over Batwing incision in terms of less SIA and better postoperative unaided visual outcome.

Limitation(s)

The limitations of this study were small sample size, short follow-up time, use of auto keratometer for keratometry. To get better outcome; the study should be conducted with larger sample size, longer follow-up time, pentacam can be used for keratometry.

Conclusion

Cataract surgery incision causes flattening of the cornea in the same meridian and reduces existing astigmatism if used at an appropriate site. The purpose of the study was to see the beneficiary effect of an incision placed on the steepest meridian in controlling/lowering the astigmatic outcome in eyes with pre-existing astigmatism and comparing effect of incisions at different sites. Thus, the superotemporal Frown incision exhibited superior and statistically significant results in terms of lesser SIA and better unaided visual outcome when compared with superotemporal Batwing incision. However, further studies are required and should be channelised with large sample size in order to evaluate and validate the parameters and their corresponding results.

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DOI and Others

DOI: 10.7860/JCDR/2023/61713.17604

Date of Submission: Nov 23, 2022
Date of Peer Review: Feb 10, 2023
Date of Acceptance: Feb 18, 2023
Date of Publishing: Mar 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 10, 2022
• Manual Googling: Feb 13, 2023
• iThenticate Software: Feb 16, 2023 (12%)

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