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This prospective study includes 80 eyes of 78 patients with cataract, who had manual phacoemulsification operated upon by the same surgeon at Basrah Hospitals between Feb, 2006 and Jul, 2007. They were 35 males and 43 females, 2 of them (females) have cataract in both eyes. The age of patients range from 35-70 years, 23 eyes of 21 patients (28.7%) at age of between 35-45 years, 20 eyes (25%) at age of between 46-55 years, 27 eyes (33.7%) at age of between 56-65 years, 10 eyes (12.5%) at age ≤ 66 years. The pre-operative visions for those patients were ranged from 6/24 to projection of light (PL), depend on the type and extent of cataract. There was selected with no significant corneal astigmatism in all of these patients. Surgery was done on 21 eyes (26%) with posterior subcapsular cataract, 20 eyes (25%) with nuclear cataract, 30 eyes (38%) with mature cataract and 9 eyes (11%) with hypermature cataract. On the first postoperative day, according to Oxford Cataract Treatment and Evaluation Team Grade (OCTET) classification the observation was: Grade 0 was reported in 46 eyes (58%), Grade I developed in 25 eyes (31%), Grade II developed in 8 eyes (10%), and Grade III developed in 1 eye (1%). On the 7th postoperative day, 54 eyes (67.5%) had Uncorrected Visual Acuity (UCVA) of good outcome, 23 eyes (28.7%) had of borderline. On day 40 postoperative, 75 eyes (93.7%) achieved a best corrected visual acuity (BCVA) of good outcome. The final refractive states in 73 eyes (91.2%) was emmetropic or within (-1) diopteric sphere of the desired refractive target without a significant astigmatism. Introduction hacoemulsification has become the procedure of choice for cataract extraction in most parts of the world which need an expensive machine and instruments. In order to obtain the advantages of a self-sealing sutureless incision at a low cost, eye surgeons in the developing world performing manual phacoemulsification with small sutureless incision cataract extraction as an alternative method 1, 2 . In our country this manual phachoemulsification procedure was done in Baghdad in ninetieth by a foreign visitor ophthalmologist's team but was not done as a routine and was not reported by Iraqi ophthalmologists until Feb, 2006. The first experience was done in Basrah hospitals. It is thought that small wound in manual phacoemulsification heals faster than conventional incision, leading to less astigmatism (high astigmatism is an important cause of poor uncorrected visual acuity after conventional extra capsular cataract extraction surgery ECCE), better uncorrected visual acuity, rapid rehabilitation, sutureless surgery and without using an expensive phaco machine with accessories which are the advantages of this surgery. This is important as many patients do not wear or cannot afford spectacles after surgery, which means that their uncorrected visual acuity is what they rely on to carry out their every day functions. A postoperative vision of 6/18 or better without spectacles is a goal which appears to be P Manual phacoemulsification in basrah; the first series from Iraq Sajid Al Assady Bas J Surg, September, 15, 2009 82 within the reach of small incision techniques for cataract surgery. Irritation and infection from sutures necessitates their removal and it seems likely that patients without sutures would be more comfortable, less likely to rub their eyes and more satisfied with surgery. However, there are concerns that the method used to remove the nucleus in manual phacoemulsification may be more traumatic to the corneal endothelium than conventional extracapsular cataract extraction and intraocular lens (ECCE/IOL) surgery. The majority of ophthalmologists in developing countries are being well trained in conventional ECCE surgery. The change to manual phacoemulsification is easier than learning real phacoemulsification, as anterior chamber dynamics in manual phacoemulsification are similar to conventional ECCE. More trials are needed to compare the different techniques and their variations, to provide better evidence of the costs and benefits. Patients and methods This study included 80 eyes of 78 patients with cataract, who had manual phacoemulsification operated upon by the same surgeon at Basrah Hospitals between Feb, 2006 and Jul, 2007. 43 had surgery in the right eye and 37 had surgery in the left eye. They were 35 males and 43 females, 2 of them are females have cataract in both eyes (Table I). The age of patients range from 35-70 years, 23 eyes of 21 patients (28.7%) age of between 35-45 years, 20 eyes (25%) age of between 46-55 years, 27 eyes (33.7%) age of between 56-65 years, 10 eyes (12.5%) age ≤ 66 years (Table II). The pre-operative visions for all patients were ranged from ≥ 6/24 to projection of light (PL). Surgery was done on 21 eyes (26%) with posterior subcapsular cataract, 20 eyes (25%) with nuclear cataract, 30 eyes (38%) with mature cataract and 9 eyes (11%) with hypermature cataract (Table III). Preoperative examination like detailed slit lamp examination, applanation tonometry, keratometry, A-scan biometry to calculate the intraocular lens with the use of SRK I or SRK II formula. The inclusion criteria for selection of cases, included cataracts with healthy endothelium (examined under high magnification using slit lamp), without coexisting ocular pathology and no significant corneal astigmatism depending on keratometer reading preoperatively. After an adequate mydriasis with tropicamide 1% and phenylephrine 10%, a local akinesia of facial nerve was performed by injection of 2% lidocaine (Van Linťs method) and a local anesthesia by injection of 0.5 cc Lidocaine subcongunctivaly near superior rectus muscle insertion. Superior rectus muscle was fixed by bridle suture, a fornix based conjunctival flap was created superiorly and minimum haemostasis achieved with bipolar diathermy. A partial thickness 5.5 mm perpendicular external scleral incision was made 2 mm behind and parallel to the limbus by using squint caliber. Scleral tunnel was constructed using a disposable angel round crescent knife and extended through sclera up to 1.0 mm into clear cornea. Additional corneal paracentesis was made on 9 o’clock site for right eyes and 3 o’clock for left eyes using a disposable paracentesis stab knife 45 side port. Through the paracentesis, hydroxy propyl methyl cellulose 2% (visco) was injected to deepen the anterior chamber (AC), and then 0.1 ml of 0.06% trypan blue was injected between the visco and anterior capsule by using a 24g needle for deep dens cataracts only to attain a uniform staining of the anterior capsule. A 3.2mm keratome was used to access the AC from the scleral tunnel and the visco with Manual phacoemulsification in basrah; the first series from Iraq Sajid Al Assady Bas J Surg, September, 15, 2009 83 trypan was aspirated by simcoe irrigation aspiration cannula (I/A) then the AC was deepened again using a new visco. A curvilinear continuous capsulorrhexis (CCC) of 6 mm diameter was initiated using a bent 26-gauge needle then completed using an utrata capsulorrhexis forceps. If the CCC margin extended to the periphery, the capsulotomy was converted to fine can opener type. The internal corneal incision was extended for about 0.5mm more than the external scleral tunnel incision in each side by keratome. Hydroprocedures were done with a 24-gauge hydrodissection cannula, the nucleus was made to rotate freely by hydroprocedures, a sinskey hook was used to prolapse one pole of the nucleus outside the capsular bag and the rest of the nucleus was wheeled out into the AC. After good cover of visco, the prolapsed nucleus was fractured (emulsified) in to two large pieces using special dissector manual fragmentation instruments through the scleral tunnel, then extracted from the eye using an irrigating vectis pressing the posterior lip of tunnel to open the valve for the exit of the fragments. The cortex was washed using a simcoe cannula and capsular bag inflated by visco again. PMMA posterior chamber intra ocular lens (PCIOL) of 5.5 mm optic was implanted in the capsular bag. The visco material was aspirated and replaced by BBS fluid, stromal hydration was performer. The integrity of the self-sealing scleral incision was ensured and the cut conjunctival flap was apposed using a forceps fitted to bipolar diathermy. Finally 20 mg gentamicin and 2 mg dexamethasone was injected Subcunjunctivaly and the eye was closed for 24 hours. Results On the first postoperative day, according to OCTET classification the observation was: Grade 0 was reported in 46 eyes (58%), Grade I developed in 25 eyes (31%), Grade II developed in 8 eyes (10%), and Grade III developed in one eye (1%) (Table V). The visual acuity on the 7th postoperative day, 54 eyes (67.5%) had an UCVA of good outcome, 23 eyes (28.7%) of borderline and 3 eyes (3.7%) of poor outcome (Table VI). The visual acuity on day 40 postoperative, 75 eyes (93.7%) achieved a BCVA of good outcome, 3 eyes (3.7%) of borderline and 2 eyes (2.5%) had poor BCVA (Table VII). The final refractive state on day 40 postoperative, 73 eyes (91.2%) was emmetropic or within (–1) diopteric Sphere (DS) of a desired target of refraction without a significant astigmatism, 3 eyes (3.7%) had (1) – (3) DS of ametropia, 2 eyes (2.5%) had (1) diopteric cylinder (DC) (1 myopic and 1 compound myopic) and only 2 eyes (2.5%) had (2) DC (1 simple myopic and 1 mixed) (Table VIII). Discussion Intraoperative findings or complications were recorded both in the case records as well as in a standard pro forma. Capsulorrhexis tear was converted to fine can-opener type of capsulotomy in 4 cases (5%) (Table IV) so that, the success rate of complete capsulorrhexis is (95%) in 76 eyes. This is in agreement to studies done by Galand A 3 and Duch Mesters 4 , while in another study of Jacob et al reports a failure of CCC with adjunct use of trypan blue in 3.85% of eyes with white cataract 5 . Meantime all

14-MANUAL PHACOEMULSIFICATION IN BASRAH; THE FIRST SERIES FROM IRAQ