Combined versus Sequential Phacoemulsification and Pars Plana Vitrectomy: A Meta-Analysis

A Neural Network for the Prediction of the Visual Acuity Gained from Vitrectomy and Peeling for Epiretinal Membrane

Purpose

A significant proportion of patients with epiretinal membrane (ERM) demonstrate improvement in visual acuity (VA) 3 months after pars plana vitrectomy (PPV) and membrane peeling. The identification of these patients before surgery is clinically relevant.

Design

This retrospective study was conducted to establish a neural network to predict improvement using preoperative clinical factors and OCT.

Subjects

A total of 427 eyes from 423 patients who underwent a PPV for primary idiopathic ERM combined with or without cataract surgery were included.

Methods

The data were automatically labeled according to whether an improvement of at least 2 logarithm of the minimum angle of resolution lines was observed. A multilayer perceptron was trained using a set of 7 clinical factors. The images were processed using a convolutional network. The output of both networks was concatenated and presented to a second multilayer perceptron. The dataset was divided into training, validation, and test datasets.

Main Outcome Measures

The accuracy of the neural network on an independent test dataset for the prediction of postoperative VA was analyzed. The impact of individual clinical factors and images on performance was assessed using ablation studies and class activation maps.

Results

The clinical factors alone demonstrated the highest accuracy of 0.74, with a sensitivity of 0.82 and a specificity of 0.67. These results were obtained after the exclusion of less significant factors in an ablation study. The inclusion of the factors age, preoperative lens status, preoperative VA, and the distinction between combined phacovitrectomy and vitrectomy yielded the most accurate results. In contrast, the use of ResNet18 as a neural network for image processing alone (0.61) or images combined with clinical factors (0.70) resulted in reduced accuracy. In the class activation map, image regions corresponding to the outer, central, and inner retina appeared to be important for the decision-making process.

Conclusions

Our neural network has yielded favorable results in predicting improvement in VA in approximately 3-quarters of patients. This artificial intelligence-based personalized therapeutic strategy has the potential to aid decision-making. Future studies are to assess the clinical potential and generalizability and improve accuracy by including a more extensive dataset.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Minimal Gas Vitrectomy and As-Needed Positioning Duration for Idiopathic Macular Holes

INTRODUCTION

This study aimed to investigate postoperative outcomes of minimal gas vitrectomy (MGV) combined with a reduced period of gas-fovea contact in the management of idiopathic full-thickness macular holes (MHs).

METHODS

This retrospective cohort study included patients who underwent surgery for MHs with minimal hole diameters of 250-800 µm and categorized them into two groups: conventional fluid-gas exchange (FGX) (38 eyes) and MGV (28 eyes), with FGX replaced by a 1.0-1.2 mL injection of pure sulfur hexafluoride after internal limiting membrane peeling. Postoperatively, patients in the MGV group were kept in a face-down position, switching to face-forward or no positioning (pseudophakia) once MH closure was confirmed by optical coherence tomography, performed every few days during the first postoperative week. The maximum duration of face-down positioning was 5 days.

RESULTS

Most baseline characteristics were comparable between the two groups except for the proportion of combined cataract surgery and the use of non-expansile gas, which were higher in the FGX group. Prone positioning time in the MGV group was shorter than that in the control group (3.8 days vs. 11.9 days). Subfoveal fluid pocket was present in 73.0% and 5.2% of eyes in the MGV and FGX groups, respectively. Twenty-seven eyes (96.4%) in the MGV group showed MH closure within 3 months. At 12 months, compared to the FGX group, the MGV group exhibited less disruption of the ellipsoidal zone (28.5% vs. 57.8%), superior visual acuity (0.33 ± 0.18 vs. 0.54 ± 0.28), and comparable MH closure rates.

CONCLUSION

In the treatment of medium-sized MHs, when compared to the FGX method, the use of a smaller volume of gas tamponade may be associated with earlier photoreceptor restoration. This method individualized prone positioning period without an immediate impact on central vision post surgery.

Refractive outcomes following simultaneous silicone oil removal and ciliary sulcus intraocular lens implantation

PurposeThis study aimed to assess the refractive outcomes following the combined intervention of silicon oil (SO) removal and ciliary sulcus intraocular lens (IOL) implantation in aphakic eyes after phacovitrectomy.MethodsA retrospective examination of medical records from patients who underwent a combined procedure of SO removal and ciliary sulcus IOL implantation from 2019 to 2022 was performed. The primary outcomes of interest included uncorrected distance visual acuity (UDVA), predictive error (PE) and mean absolute predictive error (MAE). Subgroup analyses were performed to compare outcomes between patients with and without intraoperative posterior capsulotomy.ResultsThe cohort comprised 40 eyes from 40 patients, with a mean duration of SO tamponade of 5.17 ± 1.48 months. A significant improvement in UDVA was observed from 1.58 ± 0.31 logMAR to 0.99 ± 0.31 logMAR one month postoperatively (P < 0.01). The PE was -0.73 ± 0.86 diopters (D), and the MAE was 0.90 ± 0.67 D, with 37.50% and 57.50% of cases achieving PE within ±0.5 D and ±1.0 D, respectively. No significant differences in UDVA, PE, or MAE were found between the capsulotomy and non-capsulotomy subgroups (all P > 0.05). However, a lower proportion of eyes in the capsulotomy group achieved PE within ±1.0 D compared to the non-capsulotomy group one month postoperatively (38.90% vs. 72.70%, P = 0.03).ConclusionsThe combined procedure of SO removal and sulcus IOL implantation resulted in a mild myopic shift in postoperative refraction. Intraoperative posterior capsulotomy seems to increase the lability of postoperative refractive outcomes.

Factors affecting the duration of air tamponade following vitreoretinal surgery

PURPOSE

Air as a tamponade in pars plana vitrectomy (PPV) is increasingly preferred due to its quick rehabilitation time. We aim to examine the factors affecting the absorption time of air tamponade.

METHOD

The study included 82 eyes from 78 patients who underwent PPV with air used as the tamponade. All patients underwent detailed ophthalmic examinations preoperatively and on the first and third postoperative days. The study evaluated demographic and clinical characteristics, surgical indications, and whether concurrent phacoemulsification surgery was performed. A single surgeon conducted all surgeries and examinations. The intraocular air percentage and volume in milliliters were determined. Patients were divided into two groups based on whether the intraocular air volume was reduced by more or less than 1.5 ml from the first to the third day.

RESULTS

Concurrent cataract surgery was performed in 35.4% of the eyes. All 82 eyes were pseudophakic at the end of the surgery. The mean air percentage in the eyes was 68.90% on the first day and 47.29% on the third day. Only the concurrent cataract surgery significantly shortened the air elimination time (p = 0.005). Other factors, such as diabetic retinopathy, glaucoma, and concurrent anti-VEGF therapy, did not show a significant impact.

CONCLUSION

The study concluded that concurrent cataract surgery notably reduces air tamponade duration after PPV. We think these findings are crucial for patient selection and surgical planning, especially in cases where maintaining a longer tamponade duration is critical, such as in retinal detachment or macular hole surgeries.

KEY MESSAGES

What is known The use of air as tamponade is becoming increasingly widespread in vitreoretinal surgery. What is new Compared to performing the surgeries separately, air tamponade shows faster absorption in concurrent cataract and vitreoretinal surgery. Factors such as diabetic retinopathy, glaucoma, and concurrent anti-VEGF therapy do not significantly affect the absorption time of intraocular air after vitreoretinal surgery.

Subsequent intraocular lens surgery in eyes with combined versus sequential phacovitrectomy

OBJECTIVE

To determine the risk factors for subsequent intraocular lens (IOL) surgery among eyes undergoing either combined or sequential phacovitrectomy.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Adult patients undergoing phacoemulsification at 8 United Kingdom National Health Service clinical centers between July 2003 and March 2015. Patients undergoing surgery for a dropped nucleus fragment, glaucoma, or iris problems were excluded.

METHODS

The eyes were categorized into 3 groups: with previous vitrectomy, undergoing combined phacovitrectomy, and with both previous vitrectomy and current combined phacovitrectomy. These groups were compared based on preoperative ocular and systemic factors, intraoperative findings, and the subsequent need for a second IOL surgery. The Poisson model was used to calculate adjusted relative risks (aRR).

RESULTS

5,215 eyes were included: 2,124 with previous vitrectomy, 2,512 with combined phacovitrectomy, and 579 eyes with previous vitrectomy and currently combined phacovitrectomy. The risk of subsequent IOL surgery was 0.6% (reference group) in eyes with previous vitrectomy, 1.6% (aRR 2.6, CI: 1.4-5.1) in eyes with current combined phacovitrectomy, and 3.3% (aRR 3.8, CI: 1.7-8.3) in eyes with previous plus current combined phacovitrectomy. Other significant risk factors were age (aRR 0.98/year), pseudoexfoliation (aRR 6.76, CI: 2-28), zonular dialysis (aRR 10.6, CI: 4.8-24), scleral buckle in the current surgery (aRR 8.05, CI: 4-14), and the use of silicone oil (aRR 3.6, CI: 1.6-8.4) compared to no tamponade.

CONCLUSIONS

Combined phacovitrectomy was associated with a higher risk of IOL complications than sequential surgery. This information is useful for planning surgery in patients requiring both cataract and retinal surgeries.

Challenges and outcomes of cataract surgery after vitrectomy

PURPOSE OF REVIEW

This review examines the challenges and outcomes of cataract surgery after pars plana vitrectomy (PPV), focusing on surgical techniques, timing, and complication management.

RECENT FINDINGS

Cataract formation remains the primary complication post-PPV, affecting approximately 80-100% of patients within two years. Nuclear sclerotic cataracts are most common, occurring in 60-100% of patients over 50, followed by posterior subcapsular cataracts (4-34%), which primarily affect younger and diabetic patients. PPV disrupts the normal oxygen gradient in the vitreous, resulting in a more uniform oxygen distribution and accelerating cataract formation.Post-PPV eyes present unique surgical challenges due to anatomical alterations, including zonular instability and capsular changes characterized by increased fragility, the potential for tears, and altered elasticity. Newer intraocular lens power calculations show promise, but unexpected refractive outcomes may occur. The choice between combined phacovitrectomy and sequential surgeries remains debated, with patient-specific factors guiding the approach. Visual outcomes vary depending on preexisting vitreoretinal pathologies and baseline vision before PPV. Further randomized controlled trials are needed to establish treatment guidelines and improve predictive models.

SUMMARY

Post-PPV cataract surgery presents unique challenges, including anatomical alterations and an increased risk of capsular complications. These necessitate careful consideration of the surgical approach and highlight the need for further research to optimize outcomes and establish treatment guidelines.

Postoperative Outcomes of Combined Phacovitrectomy for Epiretinal Membrane With a Concurrent Cataract vs Standalone Phacoemulsification for a Cataract

Purpose: To compare the postoperative outcomes after combined phacovitrectomy for epiretinal membrane and cataract (combined group) vs standalone phacoemulsification (control group). Methods: A systematic literature search of Ovid MEDLINE, CINAHL, and the Cochrane Library was performed. The primary outcomes were the refractive predictive error and mean absolute error expressed as the spherical equivalent. Secondary outcomes were the best-corrected visual acuity (BCVA). The weighted mean prediction error was calculated, and the mean absolute error outcomes were combined for a meta-analysis. When a meta-analysis was not feasible, a narrative synthesis was performed. Results: Of 3632 articles identified in the database search, 6 retrospective case control studies and 1 prospective case study met the inclusion criteria. The 7 studies comprised a total of 584 eyes (combined group, 278 eyes; control group, 306 eyes). The combined weighted mean (±SD) prediction error was -0.41 ± 0.85 D in the combined group, showing a myopic shift, and 0.09 ± 0.45 D in the control group. The meta-analysis for the postoperative mean absolute error showed a significant difference between groups (mean deviation, 0.10; 95% CI, 0.02-0.17; P = .01), favoring the control group. The mean BCVA was 0.34 ± 0.21 logMAR in the combined group and 0.575 ± 0.23 logMAR in the control group (Snellen equivalent, 6/12 and 6/19, respectively). Conclusions: The results of the meta-analysis showed that phacovitrectomy for ERM and concurrent cataract leads to higher prediction errors than standalone phacoemulsification for cataract. However, the postoperative BCVA was comparable between the 2 procedures.

Phacovitrectomy vs. consecutive vitrectomy for idiopathic macular holes: short and long-term outcomes and OCT image quality assessment

PURPOSE

To compare short- and long-term anatomical, functional, and refractive outcomes between combined phacovitrectomy (PVS) and consecutive vitrectomy (CVS) for idiopathic macular holes (MHs). Also, to evaluate the role of preoperative optical coherence tomography (OCT) image quality in guiding surgical selection.

METHODS

This retrospective study analyzed 183 phakic MH eyes operated between 2012 and 23, with patients divided into PVS and CVS groups. Demographic and ocular data, MH features, visual acuity (VA), refraction changes and postoperative outcomes, and follow-up details were collected. Pre- and post-operative OCT scans were evaluated for MH characteristics, OCT image quality, and surgical outcomes at short-term (≤ 3 months) and long-term (≥ 5 years) intervals.

RESULTS

The study included 144 eyes in PVS group and 39 in CVS group. Median follow-up duration was 16 months for PVS group and 72 months for CVS group (p < 0.001). Both groups showed significant VA improvements and comparable MH closure rates at short-term follow-up. However, CVS group had significantly better postoperative VA at short-term (p = 0.001) and long-term (p = 0.017) intervals. The preoperative OCT quality index did not significantly differ between groups and was ineffective in assessing cataract grade or guiding surgical decisions. Both groups experienced a myopic refractive shift, with a higher magnitude in the PVS group (p = 0.04). Postoperative complications were similar between the groups.

CONCLUSION

CVS achieves better long-term VA than PVS following MH repair, despite similar anatomical outcomes. Preoperative OCT quality index is not effective for guiding surgical decisions, and careful refractive planning is essential, especially for PVS patients, to address postoperative myopic shifts.

CLINICAL TRIAL REGISTRATION NUMBER

Not applicable.

Endothelial Cell Changes After Pars Plana Vitrectomy: A Cross-Sectional Study in a Tertiary Care Center

BACKGROUND

A wide variety of vitreoretinal diseases have been majorly treated by the use of pars plana vitrectomy (PPV) as the most commonly practiced treatment option. Despite the fact that it is the most feasible treatment modality, the probability of corneal endothelial cell damage following the treatment remains a matter of great concern. The study aims to inquire about the aftermath of PPV on endothelial cell density (ECD) and spans a time period of six months after the surgery has been performed.

METHODOLOGY

This cross-sectional study involved 20 patients who underwent PPV at Layton Rahmatullah Benevolent Trust (LRBT) Hospital Township, Lahore, Pakistan. ECD was measured using non-contact specular microscopy preoperatively and at 15 days, two months, and six months postoperatively. The main outcome measured was the change in ECD over time, and the results were analyzed using descriptive statistics via SPSS software (version 25.0, IBM Corp., Armonk, NY).

RESULTS

The mean baseline ECD was 2,421 cells/mm², which decreased to 2,185 cells/mm² by the six-month follow-up, representing an overall mean ECD loss of 13.72%. Significant reductions in ECD were observed at each postoperative time point, with the most substantial decrease occurring within the first two months post-surgery.

CONCLUSION

Corneal endothelial cells are substantially influenced by PPV, which is significantly evident by the continuous reduction in ECD following surgery. The analysis calls attention to a careful and proper post-operative observation of corneal well-being is therefore required to alleviate likely endothelial damage along with the necessity of deliberate thinking while opting for the surgical techniques. The main focus of future studies should be on how to improve the current practices involving surgical procedures to ensure minimizing the loss of endothelial cells.

Combined phacovitrectomy versus sequential surgery for idiopathic macular holes: systematic review and meta-analysis

OBJECTIVE

To compare the best-corrected visual acuity (BCVA) change, idiopathic macular (IMH) closure, and complications in IMH patients receiving combined phacovitrectomy and sequential surgery (vitrectomy followed by phacoemulsification).

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, Ovid EMBASE, and Cochrane Library databases were searched from their inception through February 2022. Randomized, controlled trials and observational studies that presented results of BCVA change, IMH closure, and surgery-related complications were included. A random-effects meta-analysis was conducted to calculate effect estimates with 95% CIs.

RESULTS

One randomized, controlled trials and 7 cohort studies with 585 patients were included. Overall, the meta-analyses of BCVA change (mean difference, -0.03; 95% CI, -0.10-0.04) and IMH closure (risk ratio = 1.04; 95% CI, 0.96-1.13) revealed no significant differences between combined phacovitrectomy and sequential surgery. The pooled risk ratios for various surgical complications such as postoperative retinal detachment, inflammation, and intraocular pressure elevation showed no significant differences between the 2 groups.

CONCLUSIONS

Similar visual gain and IMH closure rates were achieved after both combined phacovitrectomy and sequential surgery, with similar complication risks. The anatomic and functional outcomes of combined surgery were not better than those of sequential surgery. These results could serve as a reference for future trials.

Visual outcomes and complications of combined versus sequential pars plana vitrectomy and phacoemulsification for epiretinal membrane

BACKGROUND

Symptomatic epiretinal membrane (ERM) often requires surgical intervention via pars plana vitrectomy (PPV), for which cataract development is a common complication. There is insufficient data on the visual outcomes and complications of combined phacovitrectomy (COMB) in comparison to sequential PPV with deferred cataract surgery (SEQ) for ERM.

METHODS

A retrospective dataset analysis of 8 National Health Service ophthalmology departments. The main outcome measures were postoperative visual acuity (VA), operative complications, postoperative cystoid macular oedema (CMO) and recurrent ERM.

RESULTS

We included 898 and 299 eyes in the COMB and SEQ groups, respectively. Both procedures resulted in significantly better VA across all follow-up intervals (24 weeks). The proportion of eyes with Snellen VA of at least 20/40 at 12-24 weeks was comparable in both groups (47.8% [COMB] vs. 54.7% [SEQ], p = 0.4456). More eyes in the COMB group experienced posterior capsular rupture (2.9% vs. 0%, p = 0.0009) and iatrogenic retinal trauma (2.4% vs. 0%, p = 0.0023). However, regression analysis revealed that combined surgery did not predict either complication. There were no significant differences in the rates of CMO (6.5% [COMB] vs. 9% [SEQ], p = 0.1522) and recurrent ERM (2.1% [COMB] vs. 3.3% [SEQ], p = 0.2758) between both groups.

CONCLUSION

Both combined and sequential procedures are comparably effective and safe means for managing eyes with ERM.

Posterior synechia formation after phacovitrectomy - Predicting factors and the role of short-acting mydriatics

PURPOSE

To evaluate the influence of topical short-acting mydriatics on the formation of posterior synechia after phacovitrectomy surgery of pars plana vitrectomy and phacoemulsification with intraocular lens implantation.

METHODS

A prospective randomised controlled trial. Fifty-seven adult (>18 years old) patients (57 eyes) who underwent phacovitrectomy surgery at a single tertiary hospital, were randomly divided into two groups. The control group (29 eyes) received standard postoperative treatment (topical antibiotics and steroids). The study group (28 eyes) received short-acting mydriatics together with standard therapy. Patients were followed until 24 months after surgery. The primary outcome measure was the formation of posterior synechia during the follow-up period.

RESULTS

A total of 7 patients developed posterior synechia during the follow-up period (12%), 3 in the study group (11%) and 4 in the control group (14%). There was no statistical difference between the groups. Significant associations for the development of posterior synechia were surgery for retinal detachment, longer surgery duration (>93 min) and the use of tamponade, in particular silicone oil.

CONCLUSIONS

The use of topical short-acting mydriatic drops after phacovitrectomy surgery, in addition to standard post-operative treatment, did not reduce the formation of posterior synechia. However, we identified several factors that may influence or act as predictors for the development of posterior synechia: surgery for retinal detachment, using silicone oil tamponade and a longer surgery duration. Our findings may aid in the standardisation of post-phacovitrectomy surgery treatment and define potential at-risk patients who should be monitored more closely.

Dexamethasone Intravitreal Implant to Treat Persistent Full-Thickness Macular Hole

Purpose: To describe a new technique for the secondary repair of persistent full-thickness macular holes (FTMHs). Methods: This series evaluated 3 cases of a persistent FTMH after pars plana vitrectomy, internal limiting membrane peeling, and 20% sulfur hexafluoride gas tamponade. After at least 4 weeks (mean, 36.3; range, 32-40) of unsuccessful topical treatment with nonsteroidal anti-inflammatory drugs, an intravitreal dexamethasone implant was injected. Results: The intravitreal dexamethasone implant led to anatomic closure and visual improvement in all 3 cases over a 3-month follow-up. Conclusions: An intravitreal dexamethasone implant could be considered in the management of selected cases of persistent FTMH. Further studies and a consistent number of cases are needed to fully understand the role of intravitreal dexamethasone implants in persistent FTMHs.

Scleral Buckle, Vitrectomy, or Combined Surgery for Inferior Break Retinal Detachment: Systematic Review and Meta-Analysis

TOPIC

To compare outcomes of scleral buckle (SB), pars plana vitrectomy (PPV), and combined PPV-SB to treat rhegmatogenous retinal detachments (RRDs) with inferior retinal breaks (IRBs).

CLINICAL RELEVANCE

Rhegmatogenous retinal detachments with IRBs are not uncommon; their management is challenging with higher risk of failure. There is no consensus about their treatment, specifically whether SB, PPV, or PPV-SB should be performed.

METHODS

Systematic review and meta-analysis. Randomized controlled trials, case-control, and prospective/retrospective series (if n > 50) in English were eligible. Medline, Embase, and Cochrane databases were searched up to January 23, 2023. Standard systematic review methods were followed. The following outcomes at 3 (± 1) and 12 (± 3) months were evaluated: number of eyes with retinal reattachment after ≥ 1 surgeries, change in best-corrected visual acuity from preoperative to postoperative levels, and number of eyes with improvement of > 10 and > 15 ETDRS letters after surgery. Authors of eligible studies were asked for individual participant data (IPD) and IPD meta-analysis was undertaken. Risk of bias was assessed using National Institutes of Health study quality assessment tools. This study was registered prospectively in PROSPERO (CRD42019145626).

RESULTS

A total of 542 studies were identified: 15 were eligible and included and 60% were retrospective. Individual participant data was obtained from 8 studies (1017 eyes). Given that only 26 patients had received SB alone, these data were not considered in the analysis. There was no evidence for differences between treatment groups (PPV versus PPV-SB) in the probability of having a flat retina at 3 or 12 months postoperatively after 1 (P = 0.067; odds ratio [OR], 0.47; P = 0.408; OR 2.55; respectively) or > 1 (OR, 0.54; P = 0.21; OR, 0.89; P = 0.926; respectively) surgery. Pars plana vitrectomy-SB showed less improvement in vision postoperatively at 3 months (estimate, 0.18; 95% confidence interval, 0.01-0.35; P = 0.044), but this difference was no longer observed at 12 months (estimate, -0.07; 95% confidence interval, -0.27, 0.13; P = 0.479).

CONCLUSION

Available evidence suggests a lack of benefit of adding SB to PPV to treat RRDs with IRBs. Evidence, however, comes mainly from retrospective series and, thus, despite the large number of eyes included, should be interpreted with caution. Further research is needed.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Combined versus Sequential Pars Plana Vitrectomy and Phacoemulsification for Macular Hole and Epiretinal Membrane - A Systematic Review and Meta-Analysis

TOPIC

To compare the efficacy and safety between combined and sequential pars plana vitrectomy and phacoemulsification for macular hole (MH) and epiretinal membrane (ERM).

CLINICAL RELEVANCE

The standard of care for MH and ERM is vitrectomy, which increases risk of developing cataract. Combined phacovitrectomy eliminates the need for a second surgery.

METHODS

Ovid MEDLINE, EMBASE, and Cochrane CENTRAL were searched in May 2022 for all articles comparing combined versus sequential phacovitrectomy for MH and/or ERM. The primary outcome was mean best-corrected visual acuity (BCVA) at 12-months follow-up. Meta-analysis was conducted using a random effects model. Risk of bias was assessed using the Cochrane RoB 2 tool for randomized controlled trials (RCTs) and ROBINS-I tool for observational studies. (PROSPERO, registration number, CRD42021257452) RESULTS: Of the 6470 studies found, 2 RCTs and 8 non-randomized retrospective comparative studies were identified. Total eyes for combined and sequential groups were 435 and 420, respectively. Meta-analysis suggested no significant difference between combined and sequential surgery for 12-month BCVA (combined = 0.38 logMAR, sequential = 0.36 logMAR; mean difference (MD) = +0.02 logMAR; 95% CI = -0.04 to 0.08; p = 0.51, I² = 0%, n = 4 studies, 398 participants), as well as absolute refractive error (p = 0.76, I² = 97%, n = 4 studies, 289 participants), risk of myopia (p = 0.15, I² = 66%, n = 2 studies, 148 participants), MH non-closure (p = 0.57, I² = 48%, n = 4 studies, 321 participants), cystoid macular edema (p = 0.15, I² = 0%, n = 6 studies, 526 participants), high intraocular pressure (p = 0.09, I² = 0%, n = 2 studies, 161 participants), posterior capsule opacification (p = 0.46, I² = 0%, n = 2 studies, 161 participants), posterior capsule rupture (p = 0.41, I² = 0%, n = 5 studies, 455 participants) and retinal detachment (p = 0.67, I² = 0%, n = 6 studies, 545 participants).

CONCLUSION

No significant difference was detected between combined and sequential surgeries for visual outcomes, refractive outcomes, or complications. Given that most studies were retrospective and contained a high risk-of-bias, future high-quality RCTs are warranted.

Pars plana vitrectomy combined with phacoemulsification versus pars plana vitrectomy only for treatment of phakic rhegmatogenous retinal detachment: a systematic review and meta-analysis

PURPOSE

To compare the visual, refractive, and anatomical outcomes and incidence of complications between combined pars plana vitrectomy and phacoemulsification (phacovitrectomy) versus pars plana vitrectomy (PPV-only) in phakic eyes with rhegmatogenous retinal detachment (RRD).

METHODS

Two independent reviewers searched MEDLINE, Cochrane Central, and Web of Science to identify relevant articles. Prospective or retrospective studies comparing PPV-only and phacovitrectomy for RRD were included. Recruited studies provided information about at least anatomical success or refractive outcomes. Meta-analysis was performed for single surgery success rate, final best-corrected visual acuity (BCVA), postoperative complications, mean predicted refractive error, and mean absolute predicted refractive error.

RESULTS

Seven studies (788 eyes) were selected, including two clinical trials and five retrospective comparative case series. The single surgery success rate was similar in PPV-only and phacovitrectomy groups (risk ratio [RR] = 1.02; 95% confidence interval [CI] 0.95-1.10; P = 0.57). Mean final BCVA was significantly better in the PPV-only group than the phacovitrectomy group (MD = 0.06; 95% CI 0.00-0.12; P = 0.04). The risk of epiretinal membrane formation was significantly higher in eyes that underwent phacovitrectomy than PPV-only (RR = 2.85; 0.95% CI 1.5-5.41; P = 0.001). Phacovitrectomy group showed a more myopic final mean predicted refractive error than PPV-only group (MD = -0.31; 95% CI -0.55--0.07; P = 0.01).

CONCLUSION

There was no significant difference between the two groups regarding the anatomical outcome. Slightly better visual and refractive results were observed in the PPV-only group. However, the results should be interpreted with caution as the majority of included studies were low-quality retrospective studies.

Visual outcomes and complications of combined vs sequential cataract surgery and pars plana vitrectomy: multicenter database study

PURPOSE

To compare the visual outcomes and rates of intraoperative complications in eyes that underwent combined cataract extraction (CE) and pars plana vitrectomy (combined group) with those that underwent sequential surgery (sequential group).

SETTING

Multicenter study.

DESIGN

Retrospective chart review.

METHODS

CE data set pooled from 8 UK sites between 2000 and 2015. The main outcome measures were the mean postoperative visual acuity (VA) and the rate of intraoperative complications in both groups.

RESULTS

2236 eyes in the combined group and 2270 eyes in the sequential group were included in this study. Mean preoperative VA was 1.0 logMAR in both groups. The mean logMAR postoperative VA was worse in the combined group than in the sequential group ( P < .0001) at all timepoints, however, the differences in visual improvement between both groups decreased with longer follow-up time: 1.0 ± 0.7 vs 0.6 ± 0.6, 0.7 ± 0.6 vs 0.4 ± 0.5, and 0.7 ± 0.6 vs 0.5 ± 0.5 at 0 to 4 weeks, 4 to 12 weeks, and 12 to 24 weeks, respectively. Proportions of eyes that gained >3 logMAR units were 49% in the combined group and 66.2% in the sequential group ( P < .0001). Logistic regression analysis showed that sequential surgery (odds ratio, 2.1) was a predictor for reaching 20/40 vision by 6 months. In the combined group, there was a statistically significantly higher rate of posterior capsular rupture.

CONCLUSIONS

Postoperative visual gain was less in the combined group with a higher rate of posterior capsular rupture as compared with sequential phacovitrectomy. However, small differences in visual improvements between both groups by 6 months were observed.

The Postvitrectomy Cataract

To review the recent literature regarding risk factors for cataract formation after vitrectomy, the challenges and management strategies for anterior segment surgeons when facing post-vitrectomy cataract surgery, and the visual outcomes of patients undergoing post-vitrectomy cataract surgery. Cataract surgery after vitrectomy can be safely performed to significantly improve the visual outcome in most post-vitrectomy patients, although final visual acuity is primarily limited by the patient’s underlying vitreoretinal pathology.

Rhegmatogenous retinal detachment repair-does age, sex, and lens status make a difference?

PURPOSE

To analyze the correlation between lens status, age, and sex in the epidemiology and success rates of rhegmatogenous retinal detachment (RRD) surgery.

METHODS

The files of all consecutive patients undergoing vitreoretinal surgery for uncomplicated RRD between Jan 2005 und Dec 2020 were retrospectively reviewed. Successful outcome was defined as no retinal redetachment occurring within 3 months after surgery.

RESULTS

5502 eyes with uncomplicated primary RRD were included. Mean age of the patients was 61.1 years (± 13.6 SD). In the age group over 40 years, a male predominance was found. The percentage of pseudophakic RRD increased from 25 to 40% during the 15 years observation period. In the age group 50 to 69 years, patients with pseudophakic detachments were male in 786 out of 1079 cases (72.9%). In the same age group, 1285 of 2110 (60.9%) patients with phakic RRD were male. Overall, primary success rate after one procedure was 91.2% (5018 of 5502). In the phakic eyes, the primary success rate was higher in those eyes that underwent combined phacovitrectomy (93.0%), compared to those without simultaneous cataract surgery (88.7%; p = 0.002).

CONCLUSION

The ratio of male and female patients with RRD varies between age groups. The proportion of pseudophakic RRD has increased within 15 years. The male predominance in RRD is stronger in pseudophakic than in phakic eyes. In phakic eyes with RRD, a combined phacovitrectomy yielded better anatomical results.

The Role of Anterior Chamber Depth on Post-operative Refractive Error After Phacovitrectomy

Purpose

To investigate the effect of phacovitrectomy on the post-operative anterior chamber depth (ACD) and refractive outcomes, and to analyze the potential differences between vitreous filling with BSS, air and gas.

Methods

Patients who underwent phacovitrectomy were included in this study and invited for repeated post-operative examination including refraction and biometry at least 3 months after the surgery. Data retrieved included demographic information, indication for phacovitrectomy, surgical details, type of vitreous filling (BSS, air or gas), pre-operative and post-operative biometric data including K-readings, axial length (AL), and ACD, as well as spherical equivalent (SE) values of the target and final refraction.

Results

Forty-three eyes of 43 patients were included in this study, including 10 eyes filled with BSS, 18 with air and 15 with gas. The mean difference between the final measured spherical equivalent (SE) and the SE of the intended target refraction was 0.61±0.68 D (p = 0.019). Only 58.1% of eyes had a final SE within ±0.5D of the target refraction. Following surgery, AL remained unchanged, while mean pre-operative ACD increased significantly from 3.11±0.34 mm to 4.77±0.47 mm (p < 0.001). There was no difference in refractive error between the vitreous fillings and no correlation with AL or ACD.

Conclusions

Phacovitrectomy is associated with lower accuracy of post-operative refraction compared to cataract surgery. This may be attributed to a significant change in ACD, influencing the effective lens position of the IOL, and may require adjustment of the pre-operative calculations.