The second two hundred cases of endocapsular phacoemulsification: the learning curve levels off T o the Editor: Two hundred cases of endocapsular phacoemulsification cataract surgery (EPECS), being cases 101 to 300 following the original prospective series,' were evaluated. It was apparent that the learning curve had flattened considerably in that both the rate of complications and the average operating time were reduced.Posterior capsular tears occurred in three cases of these 200, giving a posterior capsular tear complication rate of 1.5%. This compares favourably with standard extracapsular cataract surgery, and is significantly better than the 11 % posterior capsular rupture rate of the first 100 cases of EPECS. In two of these cases with posterior capsular tears, the implant was satisfactorily implanted in the sulcus, and in the third, the implant was retained in the capsular bag.The average operating time, from the incision in the sterile drape to placement of the eye dressing, was 58 minutes, with the median time of 53 minutes and a range of 33 to 140 minutes. This compares favourably with the mean operating time of the first 100 cases, of 71.5 minutes.Only one of the three cases of posterior capsular tear required vitrectomy. In one further case of the two hundred, the pupil became too small to continue EPECS, and extracapsular surgery was performed. A further case was converted to extracapsular surgery following an anterior capsular tear early in the course of the operation.Of the three cases with posterior capsular tears, the one requiring vitrectomy achieved vision of 6/6 with 13 months' follow-up. Of the two others one achieved vision of 614. The final patient, a 61-year-old male with advanced renal failure and a wooden, oedematous orbit, with preoperative visual acuity of hand movements, achieved vision of 6/18 but was lost to follow-up.Ten patients sustained anterior capsular tears, and one of these required sulcus placement of the Letters to the Editor implant. A further case sustained zonulysis which occurred between 2.30 and 5 o'clock during cortex aspiration with the manual irrigatiodaspiration cannula, and this case too required sulcus placement. In this case, there was no vitreous loss, and the patient achieved vision of 6/4. In all, only four cases required sulcus futation, and 196 had capsular bag fixation.Using the 'divide and conquer' technique of nuclear disassembly allowed the surgery to be performed with improved ease in all cases, compared with 'Spring surgery'.2 It was possible to aspirate very soft nuclei (which are often seen in young patients with subcapsular cataracts) with only 5 seconds of phaco time.The reduction in operating time, reduction in numbers of major surgical complications, and the continued generation of high quality visual and functional results have contributed to the success of the EPECS procedure as the learning curve has levelled off.
