Complex three-in-one surgery may provide relief for uveitic eyes

Success of the procedure will depend on careful patient selection and the expertise of the surgeon.

Combined retinal repair, removal of opacified lens and lens exchange in one procedure is safe and may help improve vision in select patients with uveitic cataracts and posterior segment disease, according to a study.

Masoud Soheilian

The combined technique – 25-gauge vitrectomy, scleral tunnel phacoemulsification and posterior chamber IOL implantation – is a complex procedure with a steep learning curve and should only be attempted in carefully selected patients, according to principal investigator Masoud Soheilian, MD, but the combined surgery has advantages for both surgeons and patients.

“Operating times can be effectively reduced, providing easier and shorter visual rehabilitation,” Dr. Soheilian said in an e-mail interview with Ocular Surgery News. “Multiple procedures during one-stage surgery … decrease the need for multiple surgeries with general anesthesia and decrease the cost of surgery.”

At baseline, three of the 19 eyes (15.8%) in the study had visual acuity of 20/100 or better, and that number increased to 12 eyes (63.1%) by the end of the protocol with at least 12 months of follow-up. The combined procedure, which has been described previously in patients with diabetes and trauma, produced an “acceptable complication rate” in patients in the study.

Improving the inflammatory profile

Overall, the study authors said, complication rates were low and largely self-limited; however, an analysis of adverse outcomes resulting from the combined surgery is made difficult by the various underlying condition of the study eyes. Some of the complications could have been due to surgical trauma, whereas others may be attributable to progression of disease, Dr. Soheilian said.

The presence of cystoid macular edema (CME) decreased from 16 eyes preoperatively (84.2%) to 12 (63.1%) postoperatively. Other complications of note were transient corneal edema in 10 eyes (50.3%), posterior synechiae in nine eyes (47.4%) and fibrin formation in three eyes (15.8%), but there were no instances of pupillary block. Postoperative complications in a subset of patients included glaucoma in three eyes and macular scar in two eyes.

An unexpected finding in the study, Dr. Soheilian said, was the need for YAG laser capsulotomy in nine eyes (47.4%) during the first year after surgery. However, the cause of posterior capsular opacification in study eyes

remains unknown because PCO risk remained high after vitrectomy, meaning that inflammatory markers were not in close proximity with the posterior capsule.

The study found improvements in the inflammatory profile of eyes. Eight eyes had a decrease of one grade or more of inflammation postoperatively compared with baseline, an important finding because it portends less possibility for future complications.

“Preoperative, perioperative and postoperative control of inflammation is mandatory to prevent postoperative complications such as development of pupillary block, glaucoma and CME,” he said. “There is evidence that by removal of certain auto-antigens from the vitreous … the immunologic milieu of the eye changes so that postoperative uveitis and its complications diminish.”

Patient selection and surgical technique may be important factors in controlling inflammation. Uveitic cataracts should be controlled for at least 3 months before surgery, and inflammation should be controlled aggressively with medical therapy after surgery, according to Dr. Soheilian. – by Bryan Bechtel

Reference:

Soheilian M, Mirdehghan S, Peyman GA. Sutureless combined 25-gauge vitrectomy, phacoemulsification, and posterior chamber intraocular lens implantation for management of uveitic cataract associated with posterior segment disease. Retina. 2008;28:941-946.

Masoud Soheilian, MD, can be reached at the Ophthalmology Department, Labbafinejad Medical Center, Boostan 9 St., Pasdaran Avenue, Tehran, 16666, Iran; e-mail: masoud_soheilian@yahoo.com.