Combined cataract, vitreoretinal surgery a viable option in skilled hands

The combined approach is recommended especially for patients older than 60 years who are undergoing retinal surgery.

Gisbert Richard

Combined phacovitrectomy is highly recommended in all patients over the age of 60 years who must undergo retinal surgery, according to a surgeon.

“It allows better visualization of the retina and of the membranes you have to remove. In addition, cataract is a frequent complication of vitrectomy after the age of 60,” Gisbert Richard, MD, a professor at the University of Hamburg, said.

In a study he conducted using a Scheimpflug camera, cataract formation after vitrectomy was seen in 74% of the patients. Subgroup analysis showed that cataracts developed in all of the patients older than 60 years, but development was rare in patients younger than 40 years. The use of endotamponades did not influence the incidence of cataract formation.

“Another problem that is often overlooked is postoperative myopization, occurring in 35% of the cases,” he said.

Ensuring atraumatic phaco

Phacovitrectomy requires an interactive learning process between anterior and posterior segment surgeons, and the procedure has a learning curve.

“You need skilled hands because complications during phaco may lead to complications during vitrectomy, particularly if you have to peel,” Dr. Richard said.

He noted that phaco should be as atraumatic as possible. The anterior chamber should be opened by a long corneal or corneoscleral tunnel of more than 3 mm in order to tolerate the pressure increase when endotamponades are used and to allow a sufficiently large opening for cataract surgery.

“The tunnel is critical to the success of the entire procedure. Also, consider the astigmatism. Make a T-cut if necessary and perform the tunnel on the steep axis,” Dr. Richard said.

No miotics are used in the combined procedure. Viscoelastic is injected in the chamber and removed only after vitrectomy.

The capsulorrhexis should be 5 mm and curvilinear, according to Dr. Richard. During phaco, contact of the nucleus with the cornea should be avoided, and phaco time should be short, ideally less than 30 seconds.

Because the incidence of secondary cataract is higher in phacovitrectomy, all cortical cells must be removed using a bimanual technique.

Dr. Richard strongly advised implanting the IOL in the capsular bag, avoiding sulcus implantation.

Larger 6.5-mm optics are better, he said. Possible interactions with the silicone tamponade preclude using silicone lenses.

Vitrectomy approaches

“Pars plana vitrectomy can be performed using a 20-gauge or a 23-gauge technique, but 25-gauge cutters are too flexible,” Dr. Richard said.

The cutting should be done at a high speed to minimize traction. If the retina is flat, a venturi pump can be used to accelerate the procedure; a peristaltic pump is preferable if the retina is detached.

The need for small incisions has guided the technological development in both anterior and posterior segment surgery. Combined sutureless phacovitrectomy was made possible by the introduction of the small-incision transconjunctival vitrectomy approach.

“In selected, easy cases of vitreous hemorrhage, macular pucker and macular hole, this approach can be used. It allows small, self-sealing incisions, with limited surgical trauma, less postoperative inflammation and faster recovery,” Dr. Richard said.

However, because the trocar microcannula is inserted under the conjunctiva before cataract surgery, it may disturb the surgeon during the procedure. Also, the risk of hypotony is higher, as is the risk of endophthalmitis, according to some researchers.

Results of phacovitrectomy

Dr. Richard and colleagues evaluated the results of phacovitrectomy in a prospective series of 230 consecutive patients with a mean follow-up of 1.5 years. The mean age was 65 years.

They found that 160 of the patients had idiopathic epiretinal membranes, while 70 patients had retinal membranes secondary to diabetic retinopathy, previous retinal surgery, branch retinal vein occlusion, uveitis or trauma.

“At 18 months, we saw an improvement of at least two lines in 82% of the patients. Complications were rare and transient,” he said.

Patients with diabetic retinopathy are more complex cases, according to Dr. Richard. In a series of 140 patients with diabetic retinopathy, preoperative evaluation showed kidney problems, poor control of diabetes and a 40% rate of retinal detachment.

“With phacovitrectomy, the retina was reattached in 90% of the eyes and visual acuity improved in 73% of the patients. However, a higher rate of complications was reported,” Dr. Richard said. – by Michela Cimberle

• Gisbert Richard, MD, can be reached at Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany; 49-40-428032301; fax: 49-40-428034906; e-mail: richard@uke.uni-hamburg.de.

The author shows that combined phacoemulsification and pars plana vitrectomy is a safe and effective option when managing posterior segment pathologies in phakic eyes of patients over 60 years of age. Considering the advantages of the combined procedure, more surgeons may be inclined to consider it as an alternative to sequential pars plana vitrectomy followed by cataract surgery when a visually significant cataract develops in the future. Of course, the use of this option will be influenced by the retinal surgeon being comfortable with phacoemulsification surgery or having easy access to a cataract surgeon colleague to perform both surgeries in one session.

Dr. Richard’s experience is very interesting; however, this is an uncontrolled case series. Research should be undertaken to compare the simultaneous phacovitrectomy technique with the traditional sequential vitrectomy followed by cataract surgery to see if long-term outcomes are comparable. Finer nuances of outcomes, such as induced astigmatism and endothelial cell loss, will also need to be considered when comparing these two approaches, besides comparing retinal attachment and visual improvement rates.

— Som Prasad, MS, FRCSEd, FRCOphth, FACS
Wirral University Teaching Hospital, Wirral, United Kingdom