ORIGINAL PAPER

Conjunctival flap in manual sutureless small-incisioncataract surgery: a necessity or dogmatic

Punitkumar Singh • Subhadra Singh •

Gajesh Bhargav • Manju Singh

Received: 20 February 2012 / Accepted: 15 April 2012 / Published online: 26 May 2012

� Springer Science+Business Media B.V. 2012

Abstract To compare the surgical outcomes of

manual sutureless small-incision extracapsular cata-

ract surgery (MSICS) with versus without a conjunc-

tival flap for the treatment of cataracts. Prospective,

randomized comparison of 220 consecutive patients

with visually significant cataracts. Tertiary level eye

clinic. 220 consecutive patients with cataracts.

Patients assigned randomly to receive either SICS

with a conjunctival flap or without one. Operative

time, surgical complications, surgically induced astig-

matism. Both surgical techniques achieved compara-

ble surgical outcomes with comparable complication

rates. The operative time was markedly less in group

without flap (mean duration of 7.67 ± 1.45 min) than

in group with flap (mean duration of 11.46 ±

1.69 min) (p value \0.001). In the group without a

flap intraoperative pupillary miosis was significantly

greater (p value 0.039) and on postoperative day 1,

there were greater patients with a subconjunctival

bleed involving greater than one quadrant of the bulbar

conjunctiva (p value \0.0001). Also, post operative

conjunctival retraction and consequent wound expo-

sure was also significantly higher in this group (p value

0.026). However, the rate of other serious complica-

tions like any postop hyphaema, conjunctival bleb

formation, iris prolapse, tunnel stability, shallow

anterior chamber, post operative uveitis, malposi-

tioned IOL, retinal detachment, cystoid macular

edema, endophthalmitis were comparable in both.

Both MSICS with and without a conjunctival flap

achieved good surgical outcomes with comparable

complication rates. But flapless MSICS is significantly

faster. However it may be associated with higher

intraoperative miosis and greater postoperative wound

exposure.

Keywords Conjunctival flap � Scleral tunnel �Small incision cataract surgery

Introduction

In 2002, the WHO estimated that blindness affected

37 million people globally, [1]. It is estimated that

over 90 % of the world’s visually impaired live in

developing countries, [2]. In these countries, blindness

is associated with considerable disability and excess

mortality, resulting in large economic and social

consequences, [3].

Phacoemulsification is the predominant surgical

technique employed in developed countries, as studies

P. Singh (&) � S. Singh

Department of Ophthalmology, Dr. S. N. Medical

College, B 33, Subhash Enclave, Air Force Area,

Jodhpur, Rajasthan 342011, India

e-mail: singhpunit12@gmail.com

G. Bhargav

Department of Ophthalmology, Dr. S. N. Medical

College, Jodhpur, Rajasthan, India

M. Singh

M. J. Hospital, Bharatpur, Rajasthan, India

123

Int Ophthalmol (2012) 32:349–355

DOI 10.1007/s10792-012-9569-6

have suggested that phacoemulsification gives better

visual outcomes than extracapsular cataract extraction

(ECCE), [4, 5]. This is attributed in part to less

postoperative astigmatism due to the lack of sutures

and smaller size of incision (phacoemulsification

around 3 mm, ECCE around 12 mm), [6]. Phacoe-

mulsification, however, is difficult to employ in high

volume in developing countries as the technology

requires costly machinery and consumables, a perma-

nent and reliable source of electricity, regular main-

tenance, and specially trained surgeons and support

staff. Phacoemulsification can also potentially lead to

more serious complications when used to remove

extremely dense cataracts commonly encountered in

developing countries, [4].

Given these challenges, manual sutureless SICS has

been the technique increasingly employed in devel-

oping countries. Manual SICS is comparable to

phacoemulsification in achieving excellent visual

outcomes with low complication rates, but is signif-

icantly faster, less expensive and requires less

technology, [6–9].

The basis of manual small incision cataract surgery

(MSICS) is the tunnel construction for entry into the

anterior chamber. Of the conventional initial prepara-

tory steps a fornix based conjunctival flap preparation

is considered a must. We expected that this step, with

practice, may be omitted and tunnel construction may

begin directly. We conducted a study to compare the

surgical outcome of patients who underwent MSICS

utilizing a sclerocorneal tunnel, with, and without, a

conjunctival flap.

Materials and methods

In a prospective randomized case control study 220

eyes of 190 patients undergoing MSICS from May

2010 to October 2010 were randomized into two

groups. Group I (110 eyes) underwent MSICS with

tunnel construction without a conjunctival flap with-

out cautery and Group II (110 eyes) underwent MSICS

with tunnel construction with a fornix based conjunc-

tival flap with cauterization of bleeding vessels. 107

patients were male and 83 were female. Of the 30

patients who underwent bilateral surgery 17 were male

and 13 were female. 15 of these were randomized in

either group and both the eyes of a single patient were

subjected to the same group. The mean age of patients

was 58.23 ± 2.67 years in group 1 and 57.03 ±

2.35 years in group 2. Exclusion criteria were eyes

with glaucoma, pseudoexfoliation, previous surgery,

small pupil, uveitis, corneal scars, traumatic cataract,

developmental cataract, severe systemic hypertension,

coronary artery disease, diabetes, history of stroke or

transient ischemic attacks (TIAs) and bleeding diath-

esis. Patients less than 30 years of age were excluded

from the study. The surgeries were performed by the

same surgeon. Informed consent was obtained from

patients. The study was approved by the institution’s

ethics and review committee.

The intraoperative complications, time taken from

making groove to completion of surgery with hydro-

stitching of incisions, immediate postoperative find-

ings and findings on follow up at 1�, 3 months and

then at 6 months were noted. The rate of complications

in each group was compared using the two sample t test

between percentages for each complication.

Technique in Gp.I

We used the superior approach for tunnel formation

for surgery in all cases. After applying the Superior

Rectus Bridle Suture with 4-0 silk the 11 no blade on a

Bard Parkers handle was used to make the incision

groove directly through the conjunctiva, tenons, and

sclera to up to 1/3–1/2 of the scleral thickness 2–3 mm

behind the corneoscleral limbus, (Fig. 1, Video).

Fig. 1 An 11 no blade on a Bard Parkers handle is used to

create a groove directly through the conjunctiva and tenons into

the sclera

350 Int Ophthalmol (2012) 32:349–355

123

Usually the conjunctiva and the tenons retract spon-

taneously with the incision due to its inherent elasticity

and gape to provide a clear view for tunnel construc-

tion, (Fig. 2). Cautery was not used and any bleeding

was washed away with continuous irrigation of

balanced saline solution (BSS) mixed with adrenaline.

The external configuration of the incision was

usually curvilinear (antismiling) but may be oriented

straight when a small incision is being made. The

pocket tunnel was dissected with disposable metal

crescent at the bottom of the deep external cut, and it

was propagated anteriorly until it engaged the limbal

tissue, (Fig. 3). At all times the visibility of the

crescent blade through the conjunctiva and sclera was

desired for optimal tunnel depth to prevent a

premature entry into the anterior chamber. The

chamber was entered with a disposable metal kera-

tome 2.8 mm or 11 no blade on a Bard Parkers handle

and routine surgery was continued. All patients were

implanted with nonfoldable PMMA lenses (Appasamy

associates) after routine MSICS cataract surgery.

Subconjunctival amikacin and dexamethasone was

injected above and below the site of the initial

incision/groove so as to cause adequate conjunctival

ballooning so that the two end approach each other.

Technique in Gp. II

The conjunctival spring scissors was used to fashion a

fornix based conjunctival flap starting from the

limbus. The flap was extended by blunt dissection to

reach 3–4 mm behind the limbus, was retracted and

electric bipolar cautery was done. No. 11 blade on bard

parker’s knife was used to make the groove 2–3 mm

behind the limbus and then the tunnel was fashioned as

earlier. At the end of the procedure the conjunctival

flap was reapproximated at the limbus with bipolar

electric cautery.

Results

The operative time was markedly less in group 1

(mean duration of 7.67 ± 1.45 min) than in group 2

(mean duration of 11.46 ± 1.69 min). Not only this

difference was statistically significant (using the

independent groups t test between means, a p value

\0.001) but we also found that with consistent

practice the time duration in group 1 could be reduced

further substantially to about 3–4 min, though only in

uncomplicated cases.

Rate of intraoperative hyphaema due to blood

trickling into the anterior chamber through the

Fig. 2 As the groove is formed the conjunctiva may retract

above and below the wound to give a clearer view of the scleral

groove

Fig. 3 A scleral tunnel under the conjunctiva is formed using a

disposable metal crescent. Video: Video illustrating the

formation of the scleral groove and fashioning of scleral tunnel

without a conjunctival flap. An 11 no blade on a Bard Parkers

handle is used to create a groove directly through the

conjunctiva and tenons into 1/3–1/2 of the scleral thickness

2–3 mm behind the corneoscleral limbus. The scleral tunnel

under the conjunctiva is formed using a disposable metal

crescent. Care is taken to ensure the visibility of the blade

through the conjunctiva while preparing the tunnel to avoid a

premature entry. The Anterior chamber is entered with either a

45� keratome or an 11 no blade on a Bard Parkers handle

Int Ophthalmol (2012) 32:349–355 351

123

tunnel was found to be slightly higher in Grp. 1 but

the difference was not statistically significant

(Table 1).

The rate of buttonholing of the scleral flap anteri-

orly was found comparable in both groups, (p value

0.41). The rate of premature entry into the anterior

chamber was again marginally higher in Grp. 1 but the

difference was not significant statistically, (p value

0.65). Sutures were applied with 10-0 nylon suture in

such cases at the completion of surgery.

Any inadvertent descemet’s detachment was also

comparable in both groups. Intraoperative iris pro-

lapse, any iridodialysis, shallowing of the anterior

chamber, posterior capsular rupture, and vitreous loss

was comparable. Intraoperative pupillary miosis was

greater in group 1 than in group 2 and the difference

was significant (p value 0.039). Preoperative ketorolac

eye drops were not instilled in either group in any

patient.

No difference was noted in both groups in the

intraoperative maneuverability of surgical instruments

while introducing or withdrawing them from the

anterior chamber.

The postoperative patient symptomatology was

compared in both groups. Patients were asked specif-

ically regarding any grittiness, foreign body sensation,

stinging, pain, and dryness. There were no significant

differences noted between both groups.

Postoperative signs were compared. The subcon-

junctival bleed (‘‘red eye’’), exposure of the wound

due to conjunctival retraction, any postop hyphaema,

conjunctival bleb formation, iris prolapse, tunnel

stability, shallow anterior chamber, were compared

(Table 2) and the only difference found between both

groups was that on the first post op day there were

greater patients with a subconjunctival bleed on the 1st

postop day involving greater than one quadrant of the

bulbar conjunctiva in group 1 than in group 2 and

the difference was statistically significant (p value

\0.0001). For anxious patients this could be a cause

for concern but reassurance was all that was required

in most. Moreover the blood absorbed in 2–3 weeks

in most cases (Table 3). Post operative conjunctival

retraction and consequent wound exposure was also

significantly higher in group 1 (p value 0.026) but no

incidences of endophthalmitis/infective iritis were

noted in any of the cases on follow up. Moreover their

was repithelization over the wound in the majority in

the followup period of 6 months.

Other post operative complications like corneal

edema, iris prolapse, post operative uveitis, malposi-

tioned IOL, retinal detachment, cystoid macular

Table 1 Intraoperative comparision of the two groups

S. No. Complication No. of cases in group 1

and (%) (n = 110)

No. of cases in group 2

and (%) (n = 110)

p Value

1. Buttonholing of scleral flap 4 (3.63) 2 (1.81) 0.407

2. Intraoperative hyphaema 5 (4.54) 3 (2.72) 0.471

3. Premature entry in anterior chamber 3 (2.72) 2 (1.81) 0.65

4. Iris prolapse 10 (9.09) 10 (9.09) –

5. Descemet’s detachment 1 (0.9%) 2 (1.81) 0.56

6. Intraoperative miosis 12 (10.9) 4 (3.63) 0.039

p Value = 0.095 ([0.05)

Table 2 1st day post operative comparison

S. No. Complication No. of cases in group 1

and (%) (n = 110)

No. of cases in group 2

and (%) (n = 110)

p Value

1. Subconjunctival haemorrhage (red eye) 79 (71.81) 52 (47.27) 0.0001

2. Flap retraction/wound exposure 8 (7.27) 2 (1.21) 0.026

3. Hyphaema 6 (5.45) 4 (3.63) 0.517

4. Iris prolapse 1 (0.9) 2 (1.21) 0.806

5. Uveitis [/= grade 3 (50–100 cells/HPF) 7 (6.36) 5 (4.54) 0.552

352 Int Ophthalmol (2012) 32:349–355

123

edema were comparable in both groups. No case of

Endophthalmitis including acute or the delayed post

operative variety was seen in either group (Table 2).

Discussion

MSICS remains a foreign technique to a large section

of the ophthalmic fraternity in the modern world. It was

developed mainly as a cost-effective alternative to

phacoemulsification. In the evolution of cataract

surgery, manual small incision cataract surgery

(MSICS) was a later addition much after phacoemul-

sification became a popular technique. The Western

world graduated from ECCE to phacoemulsification.

In the developing countries where cost is a major issue,

MSICS was developed after the advent of phacoemul-

sification, and hence it is a relatively younger tech-

nique than the latter. It is a safe, simple, consistent,

stable, and cost-effective way of cataract removal.

Gogate et al. [6] compared phacoemulsification

with manual SICS in a randomized controlled trial of

400 eyes in India and concluded that the techniques

were comparable in efficacy and safety.

Ruit et al. [8] compared phacoemulsification with

manual SICS in a randomized controlled trial of 108

eyes in Nepal, and showed that both phacoemulsifi-

cation and manual SICS achieved comparable, excel-

lent visual outcomes.

Wound construction plays a major role in MSICS,

which may be more important than its role in

phacoemulsification, where the size, shape and type

of the wound remain the same in most of the cases.

Scleral tunnels demand preparation of a conjunctival

flap conventionally. It is usually a fornix based flap

with blunt dissection. This as expected causes variable

bleeding from the conjunctival and episcleral vessels

necessitating cauterization. In developing nations

where large number of surgeries are performed in

eye camps in one sitting this might cause significant

additional expenditures of time, energy and resources.

Self-sealing cataract incisions were mentioned by

Kratz et al. [10] in 1980 and by Girard in 1984, [11,

12]. Kratz thought of scleral tunnel as an astigmatic

neutral way of entering the anterior chamber. In 1984,

it was shown by Thrasher et al. [13] that a 9.0-mm

posterior incision induces less astigmatism than a 6.0-

mm limbal incision. Therefore conjunctival flaps were

routinely desired for all posteriorly located scleral

tunnels thereon. Pallin [14, 15] described a Chevron

shaped incision. During the same period, Singer [16]

popularized the frown incision. All these were again

scleral tunnels and conjunctival flaps were considered

as a default addition in all these tunnel preparations

and were implied to be necessary by eye surgeons

around the world.

The necessity of a conjunctival flap in ECCE

surgeries was advocated on the grounds that it

facilitates a stronger wound closure and also covers

any exposed suture knots of non absorbable nylon/silk

sutures used for wound closure. The wound stability in

MSICS is dependent on the inherent properties of the

tunnel and do not require a conjunctiva for strength

and sutures are used only in occasional cases. The

development of clear corneal incisions for phacoe-

mulsification pioneered a new era in which conjunc-

tival flaps had no role. But no decisive research has

been done which justify or negate the value of a

conjunctival flap in MSICS surgeries which developed

as a hybrid of ECCE and phacoemulsification.

In our study we did find a marginally higher risk of

complications early and late postoperative in the group

Table 3 1� month postoperative comparison

S. No. Complication No. of cases in group 1

and (%) (n = 110)

No. of cases in group 2

and (%) (n = 110)

p Value

1. Subconjunctival haemorrhage (red eye) 9 (8.12) 2 (1.81) 0.017

2. Iris prolapse 0 1 (0.9) 0.319

3. Flap retraction/wound exposure 8 (7.27) 2 (1.81) 0.053

4. Uveitis [/= grade 2 (10–20 cells/HPF) 2 (1.81) 2 (1.81) –

5. Surgically induced astigmatism

[ 1.0 D against the wound

47 (42.72) 51 (46.36) 0.489

6. Endophthalmitis 0 0 –

p Value = 0.2775

Int Ophthalmol (2012) 32:349–355 353

123

without the flap but the risks were significant only

pertaining to selected findings like wound exposure

and intraoperative miosis. The wound exposure was

not assumed to be as dangerous as in an ECCE surgery

trusting the valvular action of the tunnel in MSICS. All

these minor complications were followed up for

6 months and in no cases any major visually threat-

ening complication like epithelial downgrowth or

endophthalmitis developed. The intraoperative miosis

can be avoided by preoperative instillation of NSAID

drops (e.g. ketorolac, flurbiprofen). The postoperative

‘‘red eye’’ was considered a harmless sign and

warranted nothing more than reassurance.

Manual SICS was shown to be significantly faster

than phacoemulsification. The average operative times

plus turnover reported by Gogate et al. [7] and Ruit

et al. [8] were 15 min 30 s and 15 min 30 s for

phacoemulsification, respectively, and 8 min 35 s and

9 min for manual SICS, respectively. Venkatesh et al.

[9] conducted a study at the Aravind Eye Hospital that

showed an average operative time plus turnover of less

than 4 min per case of manual SICS. Other studies

have reported a similar manual SICS surgical rate of

12–16 cases per hour, [17]. No information is obtained

however whether conjunctival flaps were fashioned in

these cases. Manual SICS has also been shown to cost

less than phacoemulsification. Muralikrishnan et al.

[18] reported in a study in India an average cost of

US$25.55 for phacoemulsification and US$17.03 for

manual SICS.

In our study the reduced surgical time in uncom-

plicated cases was the major advantage derived in

group 1. The time can be further reduced by individual

surgeons by developing their own improvisations. We

could reduce it to as less as 3 min 30 s in few of our

cases! We all agree that less time in performing

surgery solely does not and should not be criterion for

advocacy of a surgical modification. But there are

other advantages.

There is, in some cases, more hemorrhage with a

conjunctival flap than without one. If an iridectomy is

necessary the conjunctival flap is in the way, and great

care is necessary to avoid cutting it with the scissors. If

soft cortex has to be manipulated out, its removal is

more difficult with a piece of flabby conjunctiva

hanging across the wound. Insertion of IOLs can be

sometimes difficult in posteriorly located wounds

covered with conjunctival flaps. All these difficulties

can be avoided by avoiding a flap.

We have the assumption that some of these operated

patients may require a future trabeculectomy necessi-

tating a conjunctival flap for bleb formation. If a flap has

been fashioned earlier then fibrosis at this site invariably

develops and this site cannot or should not be used for

trabeculectomy blebs. This compels the surgeon to form

trabeculectomy at another site not necessarily protec-

tively covered by the upper lid which increases the risk

of blebitis/endophthalmitis. However the conjunctiva

remains in its native state if a flap has been avoided

thereby facilitating itself to this surgical purpose. Also,

we may be preserving the anterior segment circulation

by avoiding excessive cauterization of bleeding vessels

associated with flap formation.

The making of some sort of a conjunctival flap is

probably as old as the operation of cataract extraction.

Whether a large conjunctival flap will ever be more

than the justifiable experiment of a few operators is

hard to say. It does exert a positive influence to prevent

the reopening of the wound in ECCE. However this

step may have been just adopted in MSICS as a default

addition by surgeons. We respect the desirability of

surgeons for a flap as a prophylactic measure but

would question it as a necessity.

Conclusion

Both MSICS with and without a conjunctival flap

achieved good surgical outcomes with comparable

complication rates. But flapless MSICS is significantly

faster. However it may be associated with higher

intraoperative miosis and greater postoperative wound

exposure. Flapless MSICS may be an appropriate and

faster surgical procedure for the treatment of cataracts

in the developing world.

Acknowledgments This study was performed to compare the

surgical outcomes of manual sutureless small-incision

extracapsular cataract surgery (MSICS) without versus with a

conjunctival flap for the treatment of cataracts.

Conflict of interest None.

References

1. Resnikoff S, Pascolini D, Etya’ale D, Kocur I, Pararajase-

garam R, Pokharel GP et al (2004) Global data on visual

impairment in the year 2002. Bull World Health Organ

82:844–851

354 Int Ophthalmol (2012) 32:349–355

123

2. Thylefors B (1987) A simplified methodology for the

assessment of blindness and its main causes. World Health

Stat Q40:129–141

3. Frick KD, Foster A, Bah M, Faal H (2003) The magnitude

and cost of global blindness: an increasing problem that can

be alleviated. Am J Ophthalmol 135:471–476

4. Bourne RR, Minassian DC, Dart JK, Rosen P, Kaushal S,

Wingate N (2004) Effect of cataract surgery on the corneal

endothelium: modern phacoemulsification compared with

extracapsular cataract surgery. Ophthalmology 111:679–685

5. Minassian DC, Rosen P, Dart JKG, Reidy A, Desai P, Sidhu

M (2001) Extracapsular cataract extraction compared with

small incision surgery by phacoemulsification: a random-

ised trial. Br J Ophthalmol 85:822–829

6. Gogate PM, Kulkarni SR, Krishnaiah S, Deshpande RD,

Joshi SA, Palimkar A et al (2005) Safety and efficacy of

phacoemulsification compared with manual small-incision

cataract surgery by a randomized controlled clinical trial:

six-week results. Ophthalmology 112:869–874

7. Gogate P, Deshpande M, Nirmalan PK (2007) Why do

phacoemulsification? Manual small-incision cataract surgery

is almost as effective, but less expensive. Ophthalmology

114:965–968

8. Ruit S, Tabin GC, Chang D, Bajracharya L, Kline DC,

Richheimer W et al (2007) A prospective randomized

clinical trial of phacoemulsification vs manual sutureless

small-incision extracapsular cataract surgery in Nepal. Am J

Ophthalmol 143:32–38

9. Venkatesh R, Muralikrishnan R, Balent LC, Prakash SK,

Prajna NV (2005) Outcomes of high volume cataract

surgeries in a developing country. Br J Ophthalmol

89:1079–1083

10. Colvard DM, Kratz RP, Mazzocco TR, Davidson B (1980)

Clinical evaluation of the Terry surgical keratometer. J Am

Intraocul Implant Soc 6:249–251

11. Girard LJ, Hofmann RF (1984) Scleral tunnel to prevent

induced astigmatism. In: Emery JM, Jacobson AC (eds)

Current concepts in cataract surgery: proceedings of the

eight biennial cataract surgical congress. Appleton-Cen-

tury-Crofts, Norwalk, pp 101–102

12. Girard LJ (1995) Origin of the scleral tunnel incision.

J Cataract Refract Surg 21:7

13. Thrasher BH, Boerner CF (1984) Control of astigmatism by

wound placement. J Am Intraocul Implant Soc 10:176–179

14. Pallin SL (1990) Chevron incision for cataract surgery.

J Cataract Refract Surg 16:779–781

15. Pallin SL (1991) Chevron sutureless closure: a preliminary

report. J Cataract Refract Surg 17:706–709

16. Singer JA (1991) Frown incision for minimizing induced

astigmatism after small incision cataract surgery with rigid

optic intraocular lens implantation. J Cataract Refract Surg

17:677–688

17. Prajna NV, Chandrakanth Ks, Kim R, Narendran V, Sel-

vakumar S, Rohini G et al (1998) The Madurai intraocular

lens study II: clinical outcomes. Am J Ophthalmol 125:

14–25

18. Muralikrishnan R, Venkatesh R, Venkatesh Prajna N, Frick

KD (2004) Economic cost of cataract surgery procedures in

an established eye care centre in Southern India. Ophthal-

mic Epidemiol 11:369–380

Int Ophthalmol (2012) 32:349–355 355

123