Introduction
The majority of patients who undergo cataract surgery have coexisting ophthalmologic disorders that can be tackled with conventional surgical techniques. Traditionally, a ‘combined surgery’ for the ophthalmologist included combined cataract extraction with other intraocular surgeries eg. Trabeculectomy,1 glaucoma shunt procedures,2 vitrectomy3 and penetrating keratoplasty.4, 5 Few studies of combined cataract surgery with strabismus surgery are also present, which is an example of a combined intra-ocular and extra-ocular surgery.6, 7, 8
However, literature is lacking on other extraocular procedures (eyelid, brow lift and facial surgery). Since cataract is majorly a consequence of ageing, many involutional changes occur in and around the eye, like ptosis, dermatochalasis, brow ptosis, and lid laxity. Hence, combining cataract surgery and other oculofacial procedures simultaneously aims at visual, functional and aesthetic rehabilitation at a single sitting. It helps in reducing morbidity due to multiple surgeries and the institutional as well as patient financial burden.
Barring infective conditions like hordeolum, blepharitis and acute and chronic sac infections most oculoplastic conditions are clean and non-infective and do not contribute any extra risk for intraocular complications. Oculofacial procedures like ptosis correction,9, 10 blepharoplasty,11, 12 excision of nevus,13 cyst or benign masses14 can be easily combined with cataract extraction. Hence, the lacuna regarding the possibility of safe, effective and economical combination of cataract extraction and oculofacial procedures needs to be studied.
With this article, we aim to study the possibility and feasibility of simultaneous cataract and Oculoplastic procedures. Primarily, we aim to evaluate the post-operative outcomes of combined cataract and oculoplasty surgeries.
Materials and Methods
A prospective, observational pilot study was conducted to analyse data from patients undergoing combined cataract and oculoplastic procedures. Patients with operable cataracts and non-infective oculoplastic lesions, consenting to undergo simultaneous procedures were included in the study. Institutional scientific and ethics committee clearance was obtained before enrolment of patients. All data of patients undergoing combined surgeries from May 2023 to December 2023 by oculoplastic surgeons was analysed.
Inclusion criteria
Presence of senile immature /mature cataract with eyelid abnormalities (ptosis, medial ectropion, lagophthalmos), non-infective lid masses. Contralateral or ipsilateral eye.
Patients undergoing phacoemulsification/manual small incision cataract surgery (SICS) along with simultaneous oculoplastic surgery.
Exclusion criteria
Entropion, chalazion, punctal pathologies, other local infective conditions, chronic dacryocystitis and patients not willing to have combined procedures.
Pre-operative protocol
Uncorrected visual acuity (UCVA)
Best corrected visual acuity (BCVA)
Slit lamp examination of anterior segment-to rule out infective conditions of eyes.
Fundus examination
Keratometry, biometry and IOL power calculation done.
Further examination was tailored to the concerned pathology eg. ptosis, eyelid mass excision, dermatochalasis, brow ptosis and others.
Operative protocol
Skin marking done as per oculoplasty procedure planned (e.g. lid crease and limbus marking for ptosis, brow marking for internal browpexy, skin flap marking for upper lid blepharoplasty, fat prolapse marking for lower lid blepharoplasty). Patient was prepared according to cataract surgery requirements. Local anesthesia with 2% Lignocaine mixed with 1:1,00,000 U Adrenaline and 1500U Hyaluronidase given as peribulbar block for ipsilateral eyes, Subtenon’s block and lid block for contralateral eyes. We performed phacoemulsification/ SICS using superior section. Cataract surgery was performed first, followed by the oculoplasty procedure in the same operation theatre, on the same operating table. Oculoplasty procedure was undertaken provided the cataract surgery was uneventful. Eye was bandaged with antibiotic eye ointment.
Post-operative protocol
Eye bandage was removed the next day. UCVA was documented. Anterior segment findings noted with respect to lids, wound stability, anterior chamber depth, corneal examination, pupillary examination and posterior chamber lens position. In cases of ptosis correction and upper lid blepharotomy procedures, lid contour, palpebral fissure height, margin-to-reflex distance 1 (MRD1), levator palpebralis superioris (LPS) action was measured, Bell’s phenomenon and lagophthalmos noted. Sutures if present, noted if intact. For mass excision and cyst excision procedures, wound apposition was noted, sutures if present, noted if intact. In nevus excision cases, lid margin was examined for notching or heaping of tissues from residual tumour. Brow position noted in browpexy cases. Medial and lateral canthal position noted in PMCT, lateral tarsal strip, lateral canthopexy procedures.
Results
We performed combined cataract and oculoplastic procedures in 122 patients, out of which 53 were males (43% of all patients) and 69 were females (57% of all patients), 73 were ipsilateral (60% of all cases) and 49 contralateral eyes (40% of all cases). We noticed that females were more than males. The postoperative follow-up period was 1 week and 1 month.
Figure 1
Preoperative and post-operative day 1: Right eye cataract extraction with posterior whiteline advancement
Figure 2
Preoperative and post-operative day 1: Right eye cataract extraction with upper lid blepharoplasty
Table 1
We found that ptosis correction was the most commonly performed procedure combined with cataract extraction, which accounted for 32% of all cases. Successful outcomes were noted in all cases, not requiring immediate post-operative revision. The combined procedure of ptosis correction with cataract extraction had no bearing on visual outcomes as compared to routine cataract outcomes. We noted no under or over-correction in patients undergoing ptosis correction, and theoretically, if found can be dealt with as routine ptosis correction outcomes. Wound apposition and healing found to be adequate in all cases and no infection, granuloma noted.
We did not note any hemorrhage/ hematoma in any of our patients undergoing combined procedures. No post-operative ocular inflammation/ infection was noted after cataract extraction.
Discussion
While performing combined cataract extraction and oculofacial procedures, it is important to keep in mind not to take any infective cases, lest it gravely affect the postoperative cataract outcomes leading to endophthalmitis in rare cases.15 Any suspicion of infective condition of eyelid should not be considered for combined surgery, and cataract surgery should be deferred till infective condition is resolved.
Cataract surgery should be performed first, so as to secure the wound and avoid challenges in performing cataract surgery if tissue edema develops after oculoplasty procedure. Since the intraocular wounds are self-sealing due to the pressure gradient inside and outside the eye, wound stability is maintained throughout the oculoplasty procedure. Nevertheless, care should be taken not to put undue pressure on the globe while instrumentation for oculoplasty procedures, to prevent anterior chamber collapse and globe deformation. Any suspected wound leaks should be secured with non-absorbable sutures.
In case of ptosis correction posterior approach,16 conjunctival wound is away from the intraocular wounds, hence conjunctival flora is not disturbed during the procedure. Care must be taken to protect cornea from drying and touch, while instrumentation and handling of conjunctiva and lid tissues. Rest of the oculoplasty procedures did not show any intraocular infections, as the sites of surgery are far away from the intraocular wound, thus precluding any exposure of skin flora to the intraocular wounds. Sterility is not compromised in non-infective oculoplastic conditions, hence there is no need for combined cases to be done last on the operative list.
Conclusion
Simultaneous extra-ocular and cataract surgery is an option for patients reluctant for multistage procedures either by choice or medical recommendations. It is also an alternative for patients with poor medical compliance and works in favour of ergonomics and economy. Prevention of multiple hospital visits, reduction in carbon footprint and earlier rehabilitation of patients positively impact the quality of life of patients in the early postoperative period and hence lead to patient comfort and satisfaction. Combining cataract surgery and other oculofacial procedures simultaneously aims at visual and aesthetic rehabilitation at a single sitting, speeds healing and reduces financial burden. The results through this technique are comparable with multistage procedures without any untoward complications. Through this article, we would like to highlight the possibility of combined intraocular and extraocular procedures simultaneously, minimizing patient morbidity, anaesthetic exposure and surgical cost. As opposed to conventional thinking, ptosis correction can safely be combined with cataract extraction without the need to defer one surgery for the other.
This being a pilot study has its limitations and further studies at multiple locations can make this simultaneous procedure possible.
Author Contributions
1st author has contributed to performing surgeries, collection of data, analysing of data, documentation of pre and postoperative data, obtaining patient consent, obtaining Institutional Scientific Committee and Institutional Ethics Committee approval, preparation of manuscript, proof reading of manuscript, review of literature, statistical analysis and finalisation of manuscript.
2nd author has contributed to performing surgeries, collection of data, analysing of data, documentation of pre and postoperative data, proof reading of manuscript, finalisation of manuscript and correspondence with journal.
3rd author have contributed to performing surgeries, collection of data, analysing of data, documentation of pre and postoperative data, proof reading of manuscript and finalisation of manuscript.
4th author has contributed to performing surgeries, collection of data, analysing of data, documentation of pre and postoperative data, obtaining patient consent, obtaining Institutional Scientific Committee and Institutional Ethics Committee approval, proofreading of manuscript and review of literature.
5th author has contributed to critical evaluation and editing of manuscript.
