PARS PLANA VITRECTOMY COMBINED WITH CATARACT EXTRACTION: A Comparison of Surgical Outcomes Using Single-Piece and Multipiece Foldable Intraocular Lenses

Three-year results of combined pars plana vitrectomy and phacoemulsification in diabetic vitreous hemorrhage

Aim: The purpose of this study was to evaluate the efficacy and safety of complications following combined pars plana vitrectomy and phacoemulsification surgery of the eyes for the management of vitreous hemorrhage due to proliferative diabetic retinopathy as well as pronounced cataracts. Material and Method: Phacoemulsification and 23G pars plana vitrectomy procedures were performed for the management of vitreous hemorrhage and cataracts. Age, gender, best-corrected visual acuity before and after surgery, and intra- and post-operative complications were recorded in patients with cataracts who underwent surgery due to vitreous hemorrhage. Results: A total of 40 eyes of 40 patients, 22 females (55%) and 18 males, were included in the study. The mean age was 58.7±7.1 (44–76) years. Logmar visual acuity changed from a mean of 2.82±0.5 preoperatively to a mean of 0.7±0.6 postoperatively. Visual acuity increased in 38 eyes (95%) postoperatively. No reduction in visual acuity was observed in any eye. Complications associated with surgery included transient intraocular pressure increase (12 eyes), hyphema (2 eyes), posterior capsule rupture (1 eye), anterior chamber fibrin exudation (4 eyes), neovascular glaucoma (1 eye), vitreous hemorrhage (4 eyes), retinal detachment (1 eye), and posterior capsule opacification (2 eyes). Conclusion: It was found that combined phacoemulsification and PPV surgery was safe and effective in patients with proliferative diabetic retinopathy. Combined phaco-vitrectomy is a reliable method with a minimum complication profile and prevents the need for subsequent cataract surgery.

Combined phaco-vitrectomy provides lower costs and greater area under the curve vision gains than sequential vitrectomy and phacoemulsification

PURPOSE

A majority of phakic patients undergoing pars plana vitrectomy for epiretinal membrane or macular hole require subsequent cataract surgery within 1-2 years. Combined phaco-vitrectomy eliminates the need for a second surgery and may enable patients to attain their best vision sooner. This study aims to compare the visual outcomes, complication rates, and costs of combined phaco-vitrectomy versus sequential vitrectomy followed by cataract surgery.

METHODS

Records were searched by CPT® codes to identify patients with both cataract and vitrectomy surgery at our institution over a 5-year period (2013-2018). Chart review included medical history, demographics, exam findings, operating room records, visual acuity (VA), and clinical outcomes. Statistical analyses were performed with SPSS v19 (IBM). Area under the curve for visual acuity was calculated as the trapezoidal mean of the change in Early Treatment of Diabetic Retinopathy Study letters.

RESULTS

After exclusion, 81 eyes of 78 patients underwent both cataract and vitrectomy surgeries at our institution. Thirty-four eyes underwent separate, sequential vitrectomy then phacoemulsification surgery, and 47 eyes had combined phaco-vitrectomy surgery. Total operating room times (120.81 ± 3.41 vs 161.03 ± 5.45 min; p < 0.0001) and associated costs were significantly lower in the combined surgery compared with those in the sequential surgery group. Baseline and final visual acuity were similar between the two groups. Baseline VA was 35.53 letters (~ 20/200) and 32.81 letters (~ 20/220) and increased to final VA of 63.74 (~ 20/53) and 60.91 letters (~ 20/61), in the sequential and combined groups respectively. Area under the curve for vision was greater in the combined surgery group, with subjects gaining an average of + 9.11 ± 3.32 letters from sequential surgery, and + 19.53 ± 3.53 letters in the combined surgery group (p = 0.04). Additionally, patients in the combined group attained their best visual acuity 449 days (15 months) sooner than those receiving sequential surgery.

CONCLUSIONS

Combined phaco-vitrectomy surgery resulted in greater area under the curve visual acuity benefit and attainment of best visual acuity 15 months sooner compared with conventional sequential surgeries. There were no significant differences in complication rates or clinical outcomes between the groups, but operative times and costs were lower for combined surgery, supporting a favorable cost-benefit ratio. Graphical abstract.

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

Outcome and Complications of Combined Phacoemulsification and 23-Gauge Pars Plana Vitrectomy

Background

With the advances in surgical tools, simultaneous removal of cataract associated with vitreoretinal disorders is gaining popularity. This combined surgery offers several advantages besides limitations. The aim of this study is to assess the outcome and complications of phacoemulsification combined with pars plana vitrectomy (PPV).

Patients and Methods

In this retrospective review, medical charts of patients undergoing phacovitrectomy for coexisting cataract and various vitreoretinal disorders were analyzed. Patient demographics, retinal diagnosis, visual acuities (VA) in logMAR, intraocular pressure (IOP), intraoperative and postoperative complications were assessed. Clear corneal phacoemulsification and 23-gauge transconjunctival PPV were administered in all cases.

Results

Eighty-four eyes of 64 (76.2%) males and 20 (23.8%) females were enrolled. The average age of patients was 59.5 ± 13.8 (18–81). The average period of follow-up was 7.2 ± 7.5 months (1–36). The vitreoretinal diagnoses were as follows: 28 (33.3%) rhegmatogenous retinal detachment, 23 (27.4%) vitreous hemorrhage, 12 (14.3%) intraocular foreign body, 12 (14.3%) epiretinal membrane, 4 (4.8%) macular hole, 4 (4.8%) tractional retinal detachment, and 1 (1.2%) vitreomacular traction. The most common intraoperative complications were miosis and rupture of the posterior capsule (92.9% and 8.3%, respectively). In 8 (9.5%) cases, there was fibrin in the anterior chamber. Posterior synechia developed in 7 (8.3%) of cases. No severe increase in intraocular pressure was evident.

Conclusion

Phacoemulsification combined with PPV is a safe and efficient way of management in cases where cataract coexists with vitreoretinal pathologies.

Comparison of 1.8-mm incision versus 2.75-mm incision cataract surgery in combined phacoemulsification and 23-gauge vitrectomy

PURPOSE

To compare 1.8 mm micro-incision and 2.75 mm standard incision in coaxial cataract surgery combined with 23-Gauge (23G) vitrectomy with respect to intraoperative and postoperative complications and outcomes.

METHODS

In this prospective study 30 eyes of 30 patients planned for combined phacoemulsification and 23G vitrectomy were enrolled, and randomized to undergo either Standard 2.75 mm Incision Cataract Surgery (SICS, 15 eyes) or Coaxial 1.8 mm Micro-Incision Cataract Surgery (C-MICS, 15 eyes) followed by vitrectomy. Inclusion criteria were cataract and macular disorders including macular hole, epiretinal membrane and vitreomacular traction. Data were collected at preoperative evaluation and 1 and 12 months or more after surgery.

RESULTS

Incision leakage occurred in two eyes (7%: one per group), retinal break in nine (30%: four in C-MICS, five in SICS). Fibrin in anterior chamber (AC) occurred day 1 in three eyes (10%: two C- and one SICS). Posterior capsule opacification developed in 22 eyes (78%: 13 MICS, nine SICS, p = 0.1). A myopic shift of -0.63 ± 0.7 was noted (-0.59 ± 0.8 MICS, -0.68 ± 0.6 SICS, p = 0.74). Surgically induced astigmatism (SIA) was significantly smaller in C-MICS group (ΔKP, -0.019 ± 0.095 versus -0.141 ± 0.219, p = 0.0038) at 1 month but not at final follow-up (ΔKP, 0.0005 ± 0.16 in C-MICS versus -0.057 ± 0.12, p = 0.3 CONCLUSIONS: Both techniques were equally safe with respect to intraoperative and postoperative findings. Coaxial micro-incision cataract surgery (C-MICS) was associated with less surgically-induced astigmatism (SIA) 1 month after surgery but differences were not statistically significant at final follow-up indicating a faster refractive recovery with C-MICS than with SICS.

Surgical and Functional Results of Hybrid 25-27-Gauge Vitrectomy Combined with Coaxial 2.2 mm Small Incision Cataract Surgery

Purpose. To investigate outcomes after coaxial 2.2 mm small incision cataract surgery combined with hybrid 25-27-gauge vitrectomy in eyes with vitreoretinal disease and age-related cataract. Methods. A single-center, retrospective case series study of 55 subjects (55 eyes) with a mean age of 70 years who underwent combined small incision phacoemulsification, intraocular lens (IOL) implantation, and hybrid 25-27-gauge vitrectomy during the 12-month period to December 2014. Intraoperative and postoperative complications and visual results were the main outcome measures. Results. The mean follow-up period was 6 months (range: 2–18 months). Intraoperative findings were 3 retinal breaks (5.5%). No cases required corneal or scleral suture or conversion to larger-gauge vitrectomy. Postoperative complications consisted of posterior capsule opacification (12.7%), elevated intraocular pressure >30 mmHg (1.8%), and fibrin reaction (5.5%). There were no cases of hypotony (<7 mmHg), IOL decentration, or postoperative endophthalmitis. Visual acuity (mean ± SD) improved from 0.52 ± 0.6 logMAR preoperatively to 0.22 ± 0.46 logMAR at final postoperative visit (P < 0.0001). Conclusion. Surgical and visual outcomes suggest hybrid 25-27-gauge vitrectomy combined with small incision phacoemulsification and IOL implantation is feasible, safe, and effective as a one-step surgical procedure for the management of vitreoretinal pathologies and concurrent cataract.