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Benefits seen with microincision cataract vitrectomy
In a study of the combined technique, there were no postoperative cases of hypotony, IOL decentration or endophthalmitis.
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Combining small-incision cataract surgery with 27-gauge vitrectomy is a feasible way to manage eyes with both vitreoretinal disease and age-related cataract, according to a study.
“Three years ago, we converted all pars plana vitrectomy (PPV) cases to 27-gauge vitrectomy,” principal investigator Mitrofanis Pavlidis, MD, a partner and director of vitreoretinal surgery at Augencentrum Köln in Cologne, Germany, said. “The combination of 1.8-mm microincision cataract surgery with the 27-gauge vitrectomy was the logical consequence of this conversion.”
Vitrectomy in a pseudophakic eye “is more complete by shaving the anterior vitreous, without the risk of touching the lens,” Pavlidis told Ocular Surgery News. “The visibility is also better through a clear IOL.”
Easier logistics and lower overall costs add to the desirability as well.
However, cataract surgery in vitrectomized eyes “is sometimes more difficult,” Pavlidis said. “The anterior chamber is unstable because of the absence of vitreous background.”
The single-center retrospective case series, published in Retina, included 62 eyes of 62 subjects with a mean age of 70 years.
Intraoperatively, 9.7% of eyes experienced a retinal break and 1.6% a posterior capsule tear, but no cases required a corneal or scleral suture or a larger-gauge vitrectomy.
Postoperatively, 8% of eyes developed posterior capsule opacification, 6.4% elevated IOP greater than 30 mm Hg, 1.6% retinal detachment and 1.6% fibrin reaction.
There were no cases of hypotony, IOL decentration or postoperative endophthalmitis.
Visual acuity
Regarding efficacy of the combined procedure, visual acuity improved by a mean of three lines, from 20/60 preoperatively to 20/30 at the final postoperative visit.
“None of the study results surprise us,” Pavlidis said.
For enhanced results, Pavlidis recommends placing a 27-gauge trocar before phacoemulsification. Then, after completing the anterior surgery portion, “you can connect the infusion line to the trocar and pressurize the eye before inserting the next two trocars.”
Pavlidis also advocates clearing both the posterior and anterior capsules with irrigation and aspiration instruments for better visibility to the anterior retina.
In addition, four-point IOL fixation will provide “better position stability of the IOL in the capsule during and after vitrectomy,” Pavlidis said.
Lastly, position the second and third 27-gauge ports at 9 o’clock and 3 o’clock, respectively, “in order to achieve any clock position of the vitreous,” Pavlidis said. “This is a better approach than the 12 o’clock position.”
Pavlidis related many benefits of 1.8-mm phacoemulsification: Only two incisions are needed — the main 1.8-mm incision at 10 o’clock and the 1.4-mm paracentesis at 2 o’clock; the wound is astigmatism neutral due to the 90° angle of the incisions; no suturing is needed to achieve a stable anterior chamber during vitrectomy; no hydration is needed for clear cornea incisions for increased visibility during vitrectomy; better anterior chamber stability is achieved during vitrectomy; and there is less postoperative inflammation.
Benefits of 27-gauge vitrectomy
The advantages of 27-gauge vitrectomy, according to Pavlidis, are better use of a vitreous cutter as a multi-instrument, including scissors for diabetic membranes, shaving closer to the retina, and active aspiration and reflux as a backflush instrument; less scleral trauma; true sutureless vitrectomy even with silicone oils and high myopia thin scleras; enhanced postoperative patient comfort; faster visual rehabilitation; less postoperative vitreous incarceration in the sclerotomy; fewer cases of postoperative hypotony; and less postoperative irritation and inflammation.
“Hopefully, there is also less endophthalmitis, but this was not part of the study,” Pavlidis said.
But there are limitations to performing 27-gauge PPV.
“It requires a longer learning curve than either 23 gauge or 25 gauge because of instrument flexibility,” Pavlidis said. “Fortunately, instruments are becoming stiffer over time, thanks to the development of stiffer metal materials and new sophisticated static designs.”
There is also a 2 to 4 minute longer procedure time, “due to slower flow,” Pavlidis said.
Pavlidis is the author of a recently published study in the Journal of Ophthalmology that shows that a new double-cutting vitrectomy system in combination with a faster linear vacuum intelligence pump “reduces vitrectomy case time dramatically,” he said. – by Bob Kronemyer
- References:
- Pavlidis M. J Ophthalmol. 2016;doi:10.1155/2016/3849316.
- Pavlidis M, et al. Retina. 2016;doi:10.1097/IAE.0000000000001052.
- For more information:
- Mitrofanis Pavlidis, MD, can be reached at Augencentrum Köln, Josef St. 14, 51143 Cologne, Germany; email: pavlidis@email.de.
Disclosure: Pavlidis reports he is a consultant for DORC International BV.