In the case of a completely descended nucleus, should the cataract surgeon implant an IOL before referring the case to a retinal surgeon? Why or why not?

Good idea in most cases

George A. Williams

From a retinal perspective, I encourage anterior segment surgeons to be conservative in the primary management of dislocated nuclear fragments. Surgical maneuvers such as attempts to “float” lens fragments anteriorly with viscoelastics or even perfluorocarbon liquids may lead to significant vitreous traction, which, in the absence of a complete posterior vitrectomy, is a risk factor for additional complications. Recently, a pars plana approach to remove lens fragments at the time of cataract surgery has been suggested. This approach may be effective in select cases, but without the benefits of endoillumination and wide field viewing, a complete vitrectomy is impossible, and residual lens fragments are common.

Once lens fragments are lost into the vitreous cavity, the anterior segment surgeon should determine whether placement of an IOL is still advisable. I think that in most cases, placement of an IOL at the time of the initial cataract surgery is a good idea whenever possible. The anterior segment surgeon is in the best position to assess capsular integrity to determine if posterior chamber lens placement in either the capsular bag or sulcus is possible.

Any subsequent problems with lens positioning can be addressed at the time of posterior vitrectomy and removal of the lens fragments. If there is inadequate capsular support, the anterior segment surgeon can consider a variety of sutured options or an anterior chamber lens. The placement of an IOL at the primary surgery facilitates subsequent posterior vitrectomy and any required retinal procedures.

George A. Williams, MD, is an OSN Retina/Vitreous Board Member.

It can depend on the situation

At our surgical center at Wills Eye Institute, we have the luxury of having cataract surgery performed in a room adjacent to the retina surgeon’s room, so vitrectomy can be performed on the spot if needed. In those cases, it is preferable to delay IOL implantation to the conclusion of the vitrectomy in order to facilitate access to the anterior chamber through the pars plana approach and through the rent in the capsule to aid in vitreous and lens cortex removal.

Mitchell S. Fineman

For cases referred from outside our hospital system, my preference is for the anterior surgeon to perform an anterior vitrectomy to clear as much vitreous and lens cortex as possible, and then to insert the lens at the time of the cataract procedure. This allows the cataract surgeon to implant the lens through a small incision using a foldable lens. The IOL provides tension on the capsule and makes it less likely that further damage to the capsular support will occur during the vitrectomy.

In these cases, I would recommend a nylon suture to close the cataract wound so that manipulation of the eye during vitrectomy does not lead to leaking of the cataract wound and subsequent flattening of the anterior chamber. An anterior iridectomy would be helpful in cases in which there is a risk of vitreous prolapsing into the anterior chamber causing angle-closure glaucoma.

There may be a small number of cases in which implanting an IOL is undesirable before referral. For instance, if there is a significant amount of retained cortex or a significant amount of vitreous that has prolapsed forward into the anterior chamber or to the wound. If lens material and vitreous cannot be sufficiently removed by the cataract surgeon through the anterior approach, then I think it would be beneficial to leave the patient aphakic until the time of vitrectomy.

For the patient whose inflammation is under control and whose pressure is within the normal range, there is no need to perform the vitrectomy on an urgent basis. In fact, it is reasonable to let the eye quiet down for 1 to 2 weeks before the vitrectomy is performed to remove the retained lens material.

Mitchell S. Fineman, MD, is an ophthalmologist at Mid Atlantic Retina and Wills Eye Institute in Philadelphia.