If the patient is very nervous, the doctor may administer a sedative intravenously. Desai Eye Hospital in Pune, India.

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The authors also note that the average time required for a SICS procedure was significantly less than that for phaco 8 minutes, 35 seconds vs. Phaco also requires longer training and, thus, more experienced and better paid surgeons. Surgeons trained in conventional extracapsular surgery find it easier to learn SICS than phaco, the authors add, making it a better solution for developing countries, where ophthalmologists are in short supply.

SICS, a realistic solution. The lead author of the paper, Dr. Gogate, is medical director of the H. Desai Eye Hospital in Pune, India.

He noted that there are more than 15, ophthalmologists in India and more than half do not know how to do phaco. While there is public health care available to those who cannot pay, government hospitals do not offer phaco because of the cost.

Even those patients who can afford private health care may not be able to afford the cost of phaco. At one institution in India that offers phaco, the L. Prasad Eye Institute in Hyderabad, Prashant Garg, MD, a senior ophthalmologist-consultant in the cornea and anterior segment service, estimates that 95 percent of his cases are done with phaco.

Prasad Eye Institute is supported by grants and donations, it can afford the cost of the more expensive procedure. Gogate and Garg noted that as India has become more industrialized, phaco has been increasing.

While the best centers in the developing world are adopting phaco slowly, along with foldable IOLs, millions of people in the developing world are going untreated for cataracts, according to both Dr. Gogate and the authors of another paper by Ruit and colleagues in the American Journal of Ophthalmology.

Hard cataracts need SICS. The authors of the AJO report point out that as well as requiring expensive equipment and training, phaco often is not the best solution for the brunescent hard cataracts that are typical of populations in the developing world.

These cataracts make phaco more difficult and time-consuming, they write, and prone to complication. In fact, in that report, which contrasted phaco with SICS in a series of patients with advanced cataracts in a rural Nepalese clinic, those patients randomly assigned to either surgery had similar uncorrected visual acuity one day postoperatively.

The outcomes at six months were also comparable. The surgical time for SICS was also significantly shorter than for the phaco surgeries—nine minutes vs. And the surgeons used Indian-made PMMA lenses, which are less expensive than foldable lenses for phaco surgeries. For this reason, we believe that manual SICS is the more appropriate technique for addressing the large and growing backlog of blinding cataracts in the developing world.

There is also more risk of corneal edema on the first postoperative day than with phaco, he added. In the Ruit paper, posterior capsular opacification was a greater risk in the group that received SICS than in the phaco group. High local prevalence of hard, mature cataracts. Gogate performs both types of surgeries, but he explains that for the extremely hard cataracts seen commonly in India, he prefers manual sutureless small-incision extracapsular extraction.

And in India very mature cataracts are more common that those seen in the United States, he explained, because patients tend to be less able to afford surgery—and thus they put off obtaining medical care. Those who are senior citizens may also put off treatment because they have a fear of cataract surgery.

Many remember the poor outcomes from cataract surgery of 10 to 20 years ago, when the technology in India was much less sophisticated, Dr. He has found that cataract surgery outcomes are much better with phaco compared with standard extracapsular surgery.

Free practice tests, answer keys and student instructions are available on the official website , along with links to other practice materials. Edit Examination for the Certificate of Competency in English. Test takers listen to some short conversations between two speakers.

Each conversation is followed by a question with three answer choices shown as pictures. Grammar, vocabulary, reading 90 minutes Grammar section 35 multiple-choice questions and Vocabulary section 35 multiple-choice questions: Test takers are asked to complete the sentence by selecting the most appropriate word or phrase from four options.

Reading section 30 multiple-choice questions: The following text types are included in each of the two sets of four passages: Text A up to 80 words: Text B up to words: Writing 30 minutes The test taker reads a short excerpt from a newspaper article and then writes a letter or essay giving an opinion about a situation or issue.

There is no word limit but test takers are advised to write about one page. Speaking 15 minutes A structured one-on-one interaction between an examiner and a test taker, with 4 tasks: Task 1 2—3 minutes: A new test form is developed each time the exam is administered.

It is accepted by universities, governments and employers in many countries around the world, [4] including: Ministry of Education and Science Argentina e.

Banco do Brasil Chile e. In phacoemulsification, the surgeon uses an ultra-sound probe inserted through the incision to break up the nucleus of the lens into smaller pieces. The newer technique offers the advantages of a smaller incision than standard ECCE, fewer or no stitches to close the incision, and a shorter recovery time for the patient. Its disadvantages are the need for specialized equipment and a steep learning curve for the surgeon. One study found that surgeons needed to perform about cataract extractions using phacoemulsification before their complication rates fell to a baseline level.

The diagnosis of cataract is usually made when the patient begins to notice changes in his or her vision and consults an eye specialist. In contrast to certain types of glaucoma, there is no pain associated with the development of cataracts. The specific changes in the patient's vision depend on the type and location of the cataract. Nuclear cataracts typically produce symptoms known as myopic shift in nearsighted patients and second sight in farsighted patients.

What these terms mean is that the nearsighted person becomes more nearsighted while the farsighted person's near vision improves to the point that there is less need for reading glasses. Cortical and posterior subcapsular cataracts typically reduce visual acuity; in addition, the patient may also complain of increased glare in bright daylight or glare from the headlights of oncoming cars at night. Because visual disturbances may indicate glaucoma as well as cataracts, particularly in older adults, the examiner will first check the intraocular pressure IOP and the anterior chamber of the patient's eye.

The examiner will also look closely at the patient's medical history and general present physical condition for indications of diabetes or other systemic disorders that affect cataract development. The next step in the diagnostic examination is a test of the patient's visual acuity for both near and far distances, commonly known as the Snellen test.

If the patient has mentioned glare, the Snellen test will be conducted in a brightly lit room. The examiner will then check the patient's eyes with a slit lamp in order to evaluate the location and size of the cataract.

After the patient's eyes have been dilated with eye drops, the slit lamp can also be used to check the other structures of the eye for any indications of metabolic disorders or previous eye injury. Lastly, the examiner will use an ophthalmoscope to evaluate the condition of the optic nerve and retina at the back of the eye.

The ophthalmoscope can also be used to detect the presence of very small cataracts. Imaging studies of the eye ultrasound, MRI, or CT scan may be ordered if the doctor cannot see the back of the eye because of the size and density of the cataract. ECCE is almost always elective surgery—emergency removal of a cataract is performed only when the cataract is causing glaucoma or the eye is severely injured or infected.

After the surgery has been scheduled, the patient will need to have special testing known as keratometry if an IOL is to be implanted. The testing, which is painless, is done to determine the strength of the IOL needed. The ophthalmologist measures the length of the patient's eyeball with ultrasound and the curvature of the cornea with a device called a keratometer.

The measurements obtained by the keratometer are entered into a computer that calculates the correct power for the IOL. The IOL is a substitute for the lens in the patient's eye, not for corrective lenses. If the patient was wearing eyeglasses or contact lenses before the cataract developed, he or she will continue to need them after the IOL is implanted.

The lens prescription should be checked after surgery, however, as it is likely to need adjustment. Patients can use their eyes after ECCE, although they should have a friend or relative drive them home after the procedure. The ophthalmologist will place some medications—usually steroids and antibiotics—in the operated eye before the patient leaves the office. Patients can go to work the next day, although the operated eye will take between three weeks and three months to heal completely.

At the end of this period, they should have their regular eyeglasses checked to see if their lens prescription should be changed. Patients can carry out their normal activities within one to two days of surgery, with the exception of heavy lifting or extreme bending. Most ophthalmologists recommend that patients wear their eyeglasses during the day and tape an eye shield over the operated eye at night.

They should wear sunglasses on bright days and avoid rubbing or bumping the operated eye. In addition, the ophthalmologist will prescribe eye drops for one to two weeks to prevent infection, manage pain, and reduce swelling.

It is important for patients to use these eye drops exactly as directed. Patients recovering from cataract surgery will be scheduled for frequent checkups in the first few weeks following ECCE. In most cases, the ophthalmologist will check the patient's eye the day after surgery and about once a week for the next several weeks. This clouding, which is known as posterior capsular opacification or PCO, is not a new cataract but may still interfere with vision.

It is thought to be caused by the growth of epithelial cells left behind after the lens was removed. PCO is treated by capsulotomy, which is a procedure in which the surgeon uses a laser to cut through the clouded part of the capsule.

In the words of a British ophthalmologist, "The only obstacle lying between cataract sufferers and surgical cure is resource allocation. Mortality as a direct result of cataract surgery is very rare. On the other hand, several studies have indicated that patients over the age of 50 who undergo cataract extraction have higher rates of mortality in the year following surgery than other patients in the same age group who have other types of elective surgery.

Some researchers have interpreted these data to imply that cataracts related to the aging process reflect some kind of systemic weakness rather than a disorder limited to the eye.

The majority of these, however, are not vision-threatening. The most common complication is swelling of the cornea 9. Of these complications, only endophthalmitis and retinal detachment or tear are considered potentially vision-threatening. Standard ECCE and phacoemulsification have very similar success rates and complication rates when performed by surgeons of comparable skill and length of experience. As of there are no medications that can prevent or cure cataracts.

Many ophthalmologists, however, recommend a well-balanced diet as beneficial to the eyes as well as the rest of the body, on the grounds that some studies suggest that poor nutritional status is a risk factor for cataract. While vitamin supplements do not prevent cataracts, there is some evidence that an adequate intake of vitamins A, C, and E helps to slow the rate of cataract progression.

Elderly people who may be at risk of inadequate vitamin intake due to loss of appetite and other reasons may benefit from supplemental doses of these vitamins. Not all cataracts need to be removed. A patient whose cataracts are not interfering with his or her normal activities and are progressing slowly may choose to postpone surgery indefinitely.

It is important, however, to have periodic checkups to make sure that the cataract is not growing in size or density. In the recent past, surgeons often advised patients to put off surgical treatment until the cataract had "ripened," which meant that the patient had to wait until the cataract had caused significant vision loss and was interfering with reading, driving, and most daily activities.

At present, ophthalmologists prefer to remove cataracts before they get to this stage because they are harder and consequently more difficult to remove. In addition, a rapidly growing cataract that is not treated surgically may lead to swelling of the lens, secondary glaucoma, and eventual blindness.

In most cases, however, it is up to the patient to decide when the cataract is troublesome enough to schedule surgery. It is rarely performed at present in Europe and North America, but is still done in countries where operating microscopes and high-technology equipment are not always available.

In ICCE, the surgeon makes an incision about degrees of arc, or about half the circumference of the cornea, in order to extract the lens and its capsule in one piece. The surgeon then inserts a cryoprobe, which is an instrument for applying extreme cold to eye tissue. The cryoprobe is placed on the lens capsule, where it freezes into place. It is then used to slowly pull the capsule and lens together through the long incision around the cornea.

Because of the length of the incision needed to perform ICCE and the pressure placed on the vitreous body, the procedure has a relatively high rate of complications. In addition, the recovery period is much longer than for standard ECCE or phacoemulsification.

See also Cryotherapy for cataracts ; Phacoemulsification for cataracts. Merck Research Laboratories, A Retrospective Analysis of 2, Patients. Pesudovs, Konrad, and David B. American Academy of Ophthalmology. Box , San Francisco, CA D'Ocampo, Vicente Victor, and C. Are You at Risk for Cataract? Royal College of Ophthalmologists. Royal College of Ophthalmologists, Thomas, Ravi, and Thomas Kuriakose.

Cataract surgery is performed by ophthalmologists, who are physicians who have completed four to five years of specialized training following medical school in the medical and surgical treatment of eye disorders. Ophthalmology is one of 24 specialties recognized by the American Board of Medical Specialties.