Anterior capsule may be saved during retinal detachment surgeries with PVR

Preserving the anterior capsule may help to prevent intraoperative and postoperative complications of silicone oil or gas tamponade.

DALLAS — The anterior capsule may be preserved in eyes undergoing vitrectomy and lensectomy for retinal detachment with proliferative vitreoretinopathy, according to a recent study.

“Many experienced vitreoretinal surgeons have advocated the complete removal of the crystalline lens during vitrectomy and lensectomy in phakic eyes that have retinal detachment with proliferative vitreoretinopathy (PVR),” said Mathew W. MacCumber, MD, PhD, here at the annual meeting of the American Academy of Ophthalmology. “Intraoperative corneal folds or pupillary contraction can impair the view in these aphakic eyes. Corneal decompensation can occur due to gas or silicone oil in these eyes, and pupillary block glaucoma can occur in silicone-filled aphakic eyes. This can even occur in eyes with peripheral iridectomy if it closes due to fibrin or scar tissue formation.”

With the improving success rate of retinal reattachment, more post-detachment eyes are candidates for IOLs. “Anterior chamber IOLs are generally avoided in these eyes, and suturing of a posterior chamber IOL adds complexity to these already challenging cases,” Dr. MacCumber said.

Preserving the anterior capsule in these eyes improves the view intraoperatively by providing a smooth anterior surface after fluid-air exchange. It helps prevent inadvertent pupillary contraction during surgery. It also simplifies later placement of a posterior chamber IOL.

To determine whether this technique helps prevent intraoperative or postoperative complications of gas or silicone oil, Dr. MacCumber retrospectively reviewed 15 consecutive eyes in 15 patients who underwent vitrectomy, lensectomy and preservation of the anterior capsule for retinal detachment with PVR.

“We also wanted to find out whether this technique affects the anatomic or visual outcome and if it can aid in the maintenance of a normal iris appearance by avoiding iris manipulation and iridectomy,” he explained.

All 15 eyes included in the study had varying degrees of cataract. Eight patients were men, and seven were women. Their ages ranged from 13 to 81 years (mean 48 years). Eleven had grade C proliferative vitreoretinopathy, and it was anterior in five cases. All the others had grade A proliferative vitreoretinopathy but had high-risk characteristics, such as giant retinal tear or recurrent detachment. Silicone oil tamponade was placed in eight eyes, and gas tamponade was placed in seven eyes.

One eye had primary posterior chamber IOL placement. Eight eyes had subsequent posterior chamber IOL placement, and the silicone oil was removed at the time of posterior chamber IOL placement in the eyes that had silicone oil. Follow-up was at least 6 months, with a mean of 11.5 months. Capsular opacity was graded as clear, mild, moderate or severe at the final visit.

Surgical technique

A pars plana lensectomy was performed with the fragmentation hand piece and an irrigating butterfly needle through the opposite sclerotomy, unless the lens was very soft, in which case the irrigating butterfly needle was not used. Cortical material was removed, and the capsule was polished with a vitrectomy probe. A vacuum of 100 mm Hg was used, the vitrectomy probe was in non-cutting mode and a back-and-forth motion was used through the central portion of the anterior capsule.

“Following lensectomy, the anterior capsule was inspected using tangential light with a light pipe to ensure that the lens epithelium was removed in approximately the central 6 mm of the anterior capsule,” he said.

Two early cases that had gas tamponade had a central primary capsulotomy performed before the conclusion of procedure. In the other 13 eyes, the anterior capsule was left completely intact.

Views of the anterior capsule of an eye of a 36-year-old man at 2 years after pars plana lensectomy with preservation and polishing of the anterior capsule, pars plana vitrectomy and silicone oil tamponade for retinal detachment with PVR (case 14). Note the clear central capsule and moderate peripheral opacity. The silicone oil was not removed because of poor postoperative visual acuity.

Visual outcome

Fourteen of 15 eyes had complete retinal reattachment at the final visit. One eye had retinal re-detachment, but it only involved the macular area. Final visual acuity was better or equal to preoperative visual acuity in all eyes and improved by 4 ± 4 lines overall.

The anterior capsule remains centrally clear in the 13 eyes that did not have central capsulotomy. There were varying degrees of peripheral capsular opacity.

Three of eight eyes that received silicone oil had a small bubble of silicone in the anterior chamber at some point in the postoperative period. The corneal touch was minimal. One of eight eyes that received silicone oil had some emulsified silicone oil visible in the superior angle at the 2-year postoperative visit. No eye had corneal decompensation, pupillary block or other vision-threatening complication.

One eye with grade A proliferative vitreoretinopathy preoperatively did develop hypotony. The eye with emulsified silicone oil had an elevated intraocular pressure that was controlled medically at the 2-year visit. All other eyes had normal intraocular pressures. The iris was judged to have relatively normal appearance postoperatively, and there was generally limited posterior synechiae noted at the time of posterior chamber IOL placement.

For Your Information:

• Mathew W. MacCumber, MD, PhD, can be reached at 2800 North Sheridan Road, Ste. 200, Chicago, IL 60657; (773) 871-8444; fax: (773) 871-42816. Dr. MacCumber has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.