Vitrectomy plus phaco

Combining vitrectomy with cataract procedure has advantages 
for patient and surgeon

Roibeard O’hEineachain

Posted: Friday, June 1, 2018

Zoran Tomic speaking at the 22nd ESCRS Winter Meeting in Belgrade, Serbia

Combining cataract surgery with macular hole surgery can facilitate both procedures and reduce the risk of complications and other difficulties later on, said Zoran Tomic MD, Milos Eye Hospital, Belgrade, Serbia.
“A combined procedure eliminates the need for a second procedure, which makes it more convenient for the patient. It also enhances visual rehabilitation and decreases costs,” Dr Tomic told the 22nd ESCRS Winter Meeting in Belgrade, Serbia.
He noted that cataract is the most common complication following vitrectomy. In fact, 95% of eyes in patients older than 50 years who undergo vitrectomy develop a significant cataract within two years. Most macular hole patients are referred from cataract surgery because they asked for cataract surgery first and were then discovered to be macular hole patients.
A combined procedure provides the advantages of improved perioperative visualisation of the posterior pole and the peripheral retina, thereby allowing better control during internal limiting membrane (ILM) peeling and easier identification of small retinal tears, he pointed out. It also provides better access to the retinal periphery, allowing more complete vitrectomy, better tamponade and therefore a better result, Dr Tomic said.
He added that when cataract extraction is performed before pars plana vitrectomy (PPV), the edges of the IOL and capsular opacification may interfere with his ability to visualise the peripheral retina. Performing PPV first before cataract extraction requires two surgeries, and the existing cataract can impair the perioperative view during PPV. It also entails an increased risk of capsule tearing owing to the lack of vitreous support.

He noted that the disadvantages of a combined approach include more frequent complications such as postoperative uveitis, transient elevation of IOP, dislocation of the IOL, iris capture and cystoid macular oedema. Combined procedures are also more difficult to perform and require a longer operating time. Dr Tomic noted that there are a number of measures a surgeon may take to reduce the risks of complications in the pre-, intra- and postoperative stages of a combined procedure. Prior to the surgery the instillation of mydriatic eyedrops containing phenylephrine, cyclopentolate and tropicamide will optimise visualisation during the dual procedure, he said. Using a smaller capsulorhexis of 4.0mm will reduce the risk of iris capture, and a posterior capsulotomy will eliminate any possibility of secondary cataract. Furthermore, modern small-gauge sutureless vitrectomy prevents spikes in IOP, as excess gas escapes through the sclerotomy.

Dr Tomic noted that he and his associates at Uppsala University in Sweden first started performing combined phacoemulsification and PPV surgery in the year 2000, and the combined operations now account for 80% of their vitrectomy procedures. At his current base at Milos Hospital in Belgrade, he and his associates carried out a review of 200 consecutive eyes undergoing macular hole surgery in 2013 and 2014.
The patients in the study had a mean age of 67 years. The mean duration of macular hole was 1.5 months, ranging from two weeks to 10 months. In 100 eyes the macular hole was small, in 88 eyes it was medium-sized and 12 eyes had large long-standing macular holes. As all patients were at least 50 years old, all but one patient underwent phaco-vitrectomy. Twenty-one eyes had a clear lens, 146 had mild cataract and 32 had moderate cataract.
Dr Tomic and his associates performed the procedures using peribulbar anaesthesia, beginning with phacoemulsification and implanting a foldable acrylic IOL though a 2.4mm clear corneal incision. The surgeons performed 25-gauge PPV, induction of a posterior vitreous detachment and dual membrane-assisted inner limiting membrane peeling. Tamponade was performed with sulphur hexafluoride 20% solution. All patients underwent face-down positioning for five days, with 24-hour positioning for the first three days.
Closure of macular hole was achieved in a single surgery in 90% of eyes and in all eyes with reinjection of gas, Dr Tomic said. In addition, after a follow-up of six months, 94% of eyes had an improvement of two lines or more Snellen visual acuity. In the remaining 6% of eyes, visual acuity was unchanged. Furthermore in 84% of eyes, postoperative best corrected visual acuity improved to 0.5 or better, he noted.
Perioperative complications included retinal detachment in 0.5% of eyes and a retinal tear in 1% of eyes, Dr Tomic said. Postoperative complications included persistent macular hole in 2% of eyes. Re-opening of the macular hole occurred in no cases, and no eyes developed visual field defects. Reinjection of gas was necessary in 2% of eyes and endolaser treatment was required in 1.5% of eyes. The mean operating time was 45 minutes, ranging from 30 to 60 minutes, he added.

Zoran Tomic: