Phacoemulsification in Previously Vitrectomized Patients: An Analysis of the Surgical Results in 100 Eyes as well as the Factors Contributing to the Cataract Formation

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.

Comparison of complications and visual outcomes of combined phacovitrectomy vs stand-alone phacoemulsification: multicenter database study

PURPOSE

To compare the rates of intraoperative complications, cystoid macular edema (CME), and visual outcomes in eyes that underwent combined phacovitrectomy (Phaco-PPV) with those with stand-alone phacoemulsification.

SETTING

A multicenter database study across 8 ophthalmology departments in the United Kingdom.

DESIGN

Retrospective, nonrandomized, multicenter comparative study.

METHODS

We extracted data for patients who underwent Phaco-PPV and stand-alone phacoemulsification from January 2000 through May 2015. The primary study outcomes were the rates of intraoperative complications and CME postoperatively.

RESULTS

The study included 2222 eyes in the combined Phaco-PPV group and 112 689 in the stand-alone phacoemulsification group. The combined Phaco-PPV group had a higher incidence of posterior capsule rupture (2.7% vs 1.7%), dropped lens fragments (0.5% vs 0.2%), suprachoroidal hemorrhage (0.4% vs 0.1%), and CME (3.6 vs 1.1%) ( P < .001). The mean preoperative visual acuity (VA) was lower in the combined Phaco-PPV group, with a mean VA of 0.98 vs 0.68 logMAR (Snellen ∼20/200 vs 20/100) in the stand-alone phacoemulsification group ( P < .001). VA at 24 weeks was lower in the combined Phaco-PPV group (mean VA 0.67 vs 0.22 logMAR (Snellen ∼20/100 vs 20/32), P < .001).

CONCLUSIONS

Combined Phaco-PPV had higher rates of intraoperative complications and CME, along with a lower postoperative VA, when compared with stand-alone phacoemulsification surgery.

Assessment of Zonular Integrity in Phakic Eyes Following Pars Plana Vitrectomy Using Ultrasound Biomicroscopy: A Prospective Paired Eye Comparative Study

PURPOSE

To assess zonular integrity in phakic patients post vitrectomy using ultrasound biomicroscopy (UBM).

DESIGN

Prospective, comparative, nonrandomized, double-masked, paired eye study.

METHODS

We used ultrasound biomicroscopy (UBM) to evaluate phakic patients with a history of unilateral pars-plana vitrectomy.

INCLUSION CRITERIA

(1) phakic patients with history of pars plana vitrectomy in one eye as the only procedure; (2) normal unoperated fellow eye; and (3) complete gas or air resolution from the vitreous cavity at the time of UBM assessment.

EXCLUSION CRITERIA

(1) monocular patients; (2) history of intraoperative lenticular trauma; (3) the use of silicone oil tamponade; (4) history of trauma or pseudoexfoliation in either eye; (5) history of other ocular conditions that can affect the integrity of zonules, such as uveitis or ectopia lentis; (6) eyes with extreme myopia or long axial length (> -8.00 D or >30.0 mm); (7) history of intravitreal injection in either eye; (8) age <18 years.

TECHNIQUE

A high-frequency (50 MHz) UBM device was used by a masked technician to obtain radial section images from zonular bundles at 8 different clock positions. Image quality was assessed in real time, captured, and saved. Two experienced masked observers (H.C. and C.B.) then assessed the quality of the images and graded the zonular findings. Only patients with adequate studies have been included. A unique grading system that was specifically devised for this study was used as the following: (0) clear, well-defined zonule(s); (1) uneven, disrupted zonules or stretched zonules; and (2) extensive loss of zonules. Each clock hour was graded according to this system and the total score was then calculated for each eye. In the primary outcome, 2 main groups were analyzed: vitrectomized eyes and healthy contralateral nonvitrectomized eyes. The mean total UBM score (TUS) from each group was compared and analyzed.

RESULTS

Thirty-five patients were recruited into this study. Eleven patients were male and 24 were female. The mean age was 66.3 years. Thirty patients had vitrectomy for vitreomacular interface disorders (either macular hole or epiretinal membrane), 1 patient had vitreous hemorrhage and the remaining 4 patients had rhegmatogenous retinal detachments. With regard to tamponade agents, SF6 was used in 21 (60%) patients, air in 9 (26%) patients, and C3F8 in 5 (14%) patients. The mean TUS in the vitrectomized eyes was 2.28 (SD 1.83) vs 2.24 (SD 1.77) in the nonvitrectomized eyes (P = .9531). Overall, in the comparative analysis of mean scores based on 2 graders' assessments for each clock position in vitrectomized and nonvitrectomized eyes, there were no significant differences noted between the groups.

CONCLUSION

This study found no evidence for a difference in the mean total UBM score in eyes following vitrectomy when compared to their contralateral healthy, nonvitrectomized eyes. This likely indicates that vitrectomy may not affect the integrity of zonules in phakic patients, at least for patients with vitreomacular interface disorders undergoing uncomplicated surgery.

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.

Incidence and Outcomes of Recurrent Retinal Detachment after Cataract Surgery in Eyes with Prior Retinal Detachment Repair

OBJECTIVE

To investigate the incidence and outcomes of recurrent retinal detachment (RD) after cataract extraction (CE).

DESIGN

Retrospective case series.

SUBJECTS

Phakic eyes with RD that were successfully repaired with pneumatic retinopexy (PR), scleral buckle (SB), pars plana vitrectomy (PPV), or combined PPV/SB and subsequently underwent cataract surgery.

METHODS

A retrospective review of phakic eyes that underwent successful RD repair followed by subsequent cataract surgery between April 2012 and January 2023 was performed. Patients with multiple RD surgeries before CE and those with silicone oil tamponade before cataract surgery were excluded. Eyes that redetached were matched 1:2 with eyes that did not redetach after cataract surgery.

MAIN OUTCOME MEASURES

Incidence of redetachment after cataract surgery as well as visual and anatomic outcomes at 6 months after first redetachment and at the final visit.

RESULTS

Of 4833 phakic eyes at the time of initial RD, 1893 patients (39.2%) underwent cataract surgery. After applying exclusion criteria, 763 patients were included. The mean (standard deviation) duration of follow-up was 48.4 (29.1) months. The overall incidence of retinal redetachment after cataract surgery was 2.5% (19/763 eyes). The rate of redetachment based on the type of initial RD repair was 9.1% (1/11), 5.3% (2/38), 2.8% (9/317), and 1.8% (7/397) for PR, SB, PPV, and combined PPV/SB, respectively (P = 0.24). The median (interquartile range [IQR]; range) duration between the cataract surgery and first redetachment was 301 (104-1222; 8-2760) days. Single surgery anatomic success for the RD repair after cataract surgery was achieved in 17 eyes (89.5%) at 3 months and 14 eyes (73.7%) at 6 months and at the final visit. Final anatomic success rate for reattachment was 100% (19/19). The median (IQR) logarithm of the minimal angle of resolution visual acuity (VA) at the final visit was 1.00 (0.18-2.00, Snellen equivalent, 20/200) with significant worsening compared with vision after cataract surgery (0.18 [0.10-0.48], 20/30) (P = 0.001).

CONCLUSION

Recurrent RD was not uncommon in patients with a prior history of RD repair after CE. Reoperation resulted in relatively favorable anatomic success but there were declines in VA.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Modified Technique for Preventing Lens-Iris Diaphragm Retropulsion Syndrome in Vitrectomized Eyes during Phacoemulsification

BACKGROUND

Lens-iris diaphragm retropulsion syndrome (LIDRS) is common in vitrectomized or high myopic eyes during phacoemulsification. We evaluated the results of a modified technique for cataract treatment using phacoemulsification in vitrectomized eyes.

METHODS

In this retrospective study, we enrolled thirty-four vitrectomized eyes treated with modified phacoemulsification (Modified Group) and nineteen vitrectomized eyes treated with routine phacoemulsification (Control Group). The modified technique comprised irrigation with a balanced salt solution underneath the pupil before phacoemulsification instrument entry, lens implantation and stromal hydration to stabilize the anterior chamber and equilibrate the pressure between the anterior chamber and posterior cavity.

RESULTS

We compared the incidences of intra and postoperative complications and visual outcomes between modified and routine phacoemulsification. Pain, LIDRS and difficulty in stromal hydration were significantly more common in the Control Group than in the Modified Group (p < 0.05). There were no significant differences in the rates of posterior capsular rupture, iris trauma, lens dislocation, or posterior capsular opacification between the Modified and Control Groups (p > 0.05). However, there was no significant difference in visual acuity between the groups (p > 0.05). Complications such as loss of nuclear fragments into the vitreous cavity, cystoid macular edema, retina redetachment, suprachoroidal hemorrhage and vitreous hemorrhage did not occur either intra or postoperatively in any of our patients.

CONCLUSIONS

Our modified technique prevents LIDRS and complications arising during cataract surgery in vitrectomized eyes. Aside from this, the results of modified and routine phacoemulsification are similar in vitrectomized eyes.

Prior pars plana vitrectomy and its association with adverse intraoperative events during cataract surgery

PURPOSE

To evaluate the risk of intraoperative complications during cataract surgery in eyes with a prior vitrectomy.

METHODS

A retrospective review of data from our cataract surgery registry of all patients undergoing cataract surgery between 2014 and 2018 at the University of Colorado Hospital. Univariate and multivariate analyses were conducted, accounting for intra-patient correlation in subjects who underwent two cataract surgeries. The three main outcomes of interest, zonulopathy, posterior capsule (PC) tears and dropped lens fragments, were analysed for their association with prior pars plana vitrectomy (PPV) and clinical characteristics of patients such as history of prior intravitreal injection and surgeon level of experience.

RESULTS

10 540 eyes of 6447 patients were included in the analysis. 371 (3.5%) eyes had a prior PPV. Eyes with a prior PPV experienced more zonulopathy during cataract surgery (adjusted OR 2.2, 95% confidence interval: 1.3-3.7, p = 0.002). Combined phacoemulsification/PPV were significantly more likely to experience all 3 complications, and this effect was even greater for eyes with a prior PPV.

CONCLUSIONS

All complications were rare; however, there was a significant association with prior PPV and intraoperative zonulopathy. Cataract surgeons must be aware of a patient's prior vitrectomy and plan accordingly for the increased risk of intraoperative complications.

Cataract Surgery Considerations for Diabetic Patients

PURPOSE OF REVIEW

Given the epidemiology and demographic trends of diabetes mellitus and cataracts, ophthalmologists are likely to encounter patients with both comorbidities at an increasing frequency. Patients with diabetes represent a higher risk population than healthy patients for cataract surgery. In this review, we discuss key risks and risk-mitigation practices when performing cataract surgery on these patients.

RECENT FINDINGS

Patients with diabetes continue to represent a high-risk surgical population: Nagar et al. suggest a dose-dependent relationship may exist between number of intravitreal injections and likelihood of posterior capsular rupture. However, novel treatments are improving outcomes for patients with diabetes. Several studies have reported intracameral phenylephrine/ketorolac may reduce the incidence of post-operative cystoid macular edema while others have discussed the efficacy of pre-treatment and post-treatment with intravitreal bevacizumab on improving cataract surgery outcomes in patients with diabetic retinopathy. Pre-operatively, ophthalmologists should perform an enhanced evaluation, consider timing and lens selection decisions, and complete any appropriate pre-operative treatment. Peri-operatively, surgeons should be aware of pupillary dilation adjustments, combination surgery options, and potential complications. Post-operatively, clinicians should address pseudophakic cystoid macular edema, diabetic macular edema, diabetic retinopathy, and posterior capsular opacification.

Predicting Post-Cataract Surgery Visual Acuity in Vitrectomized Eyes: The Efficacy and Accuracy of "Lambda" Retinometry

BACKGROUND AND OBJECTIVE

Determine the ability of Lambda retinometry to predict post-cataract surgery visual acuity in vitrectomized eyes.

PATIENTS AND METHODS

Prospective study including 47 cataract surgery candidates with a history of pars plana vitrectomy (PPV). Lambda retinometry using a hand-held Lambda retinometer and best-corrected visual acuity (BCVA) were measured preoperatively, and BCVA was reassessed postoperatively.

RESULTS

Lambda predictions strongly correlated with postoperative BCVA (logarithm of the minimum angle of resolution [logMAR]) (P < .001, r² = 0.57), especially combined with preoperative BCVA (logMAR) (P < .001, r² = 0.65). In 89% of cases, postoperative BCVA was equal to or higher than the prediction. Neither cataract grades nor indications for PPV were associated with the accuracy of Lambda predictions (P = .882 and P = .790, respectively). Underestimation of visual outcome was more common than overestimation. A Lambda prediction of ≥ 20/40 (Snellen) had a positive predictive value of 85.7% and a negative predictive value of 73.6% for the postoperative outcome.

CONCLUSIONS

Lambda retinometry can reliably predict the postoperative BCVA in cataract patients who previously underwent PPV, with a tendency towards underestimation. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:535-542.].

Visual outcomes following cataract surgery with intraocular lens implantation in vitrectomized eyes among children

Purpose:

To assess the visual outcomes and associated factors in pediatric patients undergoing cataract surgery following pars plana vitrectomy (PPV).

Methods:

A total of 52 eyes of 52 children who underwent cataract surgery and intraocular lens (IOL) implantation in previously vitrectomized eyes between January 2008 and December 2017 were included in this retrospective study. Descriptive and inferential statistical measurements (Chi-square test, Fisher's exact test, odds ratio, multiple logistic regression) were done.

Results:

The mean age at PPV was 11.3 ± 2.9 years. The most common indication for PPV was retinal detachment in 43 eyes (82.69%) and vitreous hemorrhage in 6 eyes (11.53%). The mean preoperative and postoperative best-corrected visual acuity (BCVA) was 1.31 ± 0.48 logMAR (logarithm of the minimum angle of resolution) units (20/400) and 0.69 ± 0.45 logMAR units (20/100), respectively; P < 0.001. The final visual outcome was good in 37 eyes (71.15%) and poor in 15 eyes (28.85%). In mean follow-up of 4 years, 42.3% developed posterior capsular opacification, 13.5% developed glaucoma, and 3.8% had retinal redetachment after cataract surgery. In the presence of macular pathology, the visual outcome was poor (aOR [adjusted odds ratio] = 4.26, P = 0.002).

Conclusion:

Cataract surgery with IOL implantation in vitrectomized eyes among children is a safe procedure and can improve visual acuity and quality of life. However, the extent of improvement is limited by macular pathology.

Cataract Following Pars Plana Vitrectomy: A Review

Introduction: The indications for pars plana vitrectomy (PPV) have increased over the years. The vitreous is no longer considered an inert ocular structure and it is well known that its removal has anatomical and physiological consequences. The vitreous is no longer considered an inert ocular structure. The vitreous plays a key role as an intraocular physiologic oxygen regulator. In order to maintain its transparency, the crystalline lens needs protection from an excessive oxygen exposure. PPV leads to progression of nuclear sclerosis in most eyes.Methods: A systematic review of the literature was conducted using Embase and Medline databases. Articles studying the physiology, pathogenesis and surgical treatment of cataract after PPV were included in this review.Results: The pathogenesis of cataract formation after PPV remains unclear. Predisposing factors include advanced patient age, preexisting nuclear sclerosis, light toxicity, intraoperative oxidation of lens proteins, use of silicone oil or intravitreal gas, mechanical trauma and the duration of exposure to an irrigating solution.Conclusion: Cataract surgery in vitrectomized eyes presents with more technical difficulties, is more challenging and often has a higher risk of intraoperative and postoperative complications than in non vitrectomized eyes. There is no standardized technique or management in these cases; therefore, it requires more precautions during surgery.

Epiretinal membrane vitrectomy: outcomes with or without cataract surgery and a novel prognostic factor for cystoid macular edema

PURPOSE

To assess the outcomes of vitrectomy with or without cataract surgery for the treatment of idiopathic ERM in phakic eyes and evaluate predictors of functional and anatomical outcomes.

METHODS

Retrospective cohort of consecutive phakic ERM eyes distributed in three groups: a) combined (phacovitrectomy) group, b) PPV-only group, and c) consecutive group (PPV followed by cataract surgery). Main outcomes were final visual acuity (VA) and cystoid macular edema (CME) occurrence. Potential predictors of VA or CME included clinical variables and SD-OCT parameters.

RESULTS

A total of 108 eyes were included in this study. There were no differences in the final VA between consecutive and combined groups (0.22 vs 0.10 logMAR, p = 0.851). Twelve eyes from the combined group (23%) and one eye from the PPV-only group presented CME (p = 0.001). There were no differences between postoperative CME occurrence in combined versus consecutive group (12 vs 7, p = 0.38). The presence of cotton-ball sign predicted the development of CME [OR 2.86 (95%CI 1.01-8.18), p = 0.049] while separated ERM-ILM complex was found to be protective [OR 0.25 (95%CI 0.08-0.77), p = 0.015].

CONCLUSIONS

Functional and anatomical results of PPV with ERM and ILM peeling combined with cataract surgery was equivalent to the consecutive procedure, with both strategies being effective. Separated ERM-ILM complex has prognostic value in these patients, as its presence at baseline was found to be protective for postoperative CME.

[Distinctive features of phacoemulsification in previously vitrectomized eyes]

The review presents the main pathogenetic mechanisms of cataract development in an avitic eye as well as anatomical and functional changes of the eye in the state of avitria. The authors have also analyzed distinctive behavior of such eyes during phacoemulsification and surgical techniques used to answer specific avitreal phenomena.

Combined Femtosecond Laser-Assisted Cataract Surgery and Small-Gauge Pars Plana Vitrectomy Using Different Devices: A New Trend for Vitreoretinal Surgery?

BACKGROUND AND OBJECTIVE

To report the efficacy, safety, and benefits of femtosecond laser-assisted cataract surgery (FLACS) combined with sutureless 23-gauge pars plana vitrectomy (PPV).

PATIENTS AND METHODS

This multicenter, retrospective study evaluated patient records and videos of 43 cases with retinal pathologies and cataract who underwent the combined procedure.

RESULTS

In 44.2% and 55.8% of cases, respectively, the LenSx Laser (femtosecond machine; Alcon, Fort Worth, TX) and the Constellation (vitreous cutter; Alcon, Fort Worth, TX), and the Victus (femtosecond machine; Bausch + Lomb, Rochester, NY) and Stellaris PC (vitreous cutter; Bausch + Lomb, Rochester, NY) were used. No complications developed during capsulorrhexis, even without a red fundus reflex, retrobulbar block, or scleral indentation. Foldable intraocular lenses remained stable in the capsular bag during the vitreoretinal surgeries and postoperative visits. The mean times of femtosecond phacoemulsification, vitreoretinal surgery, and total surgery were 22.9 minutes ± 4.7 minutes, 43.1 minutes ± 9.8 minutes, and 65.3 minutes ± 8.6 minutes, respectively.

CONCLUSION

This emerging technology is safe and offers several potential benefits for the success of the combined procedure. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:374-379.].

Surgery for postvitrectomy cataract

BACKGROUND

Cataract formation or acceleration can occur after intraocular surgery, especially following vitrectomy, a surgical technique for removing the vitreous that is used in the treatment of many disorders that affect the posterior segment of the eye. The underlying problem that led to vitrectomy may limit the benefit from removal of the cataractous lens.

OBJECTIVES

To evaluate the effectiveness and safety of surgery versus no surgery for postvitrectomy cataract with respect to visual acuity, quality of life, and other outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 5), MEDLINE Ovid (1946 to 17 May 2017), Embase.com (1947 to 17 May 2017), PubMed (1946 to 17 May 2017), Latin American and Caribbean Health Sciences Literature database (LILACS) (January 1982 to 17 May 2017), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com); last searched May 2013, ClinicalTrials.gov (www.clinicaltrials.gov); searched 17 May 2017, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 17 May 2017. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) and quasi-RCTs that had compared surgery versus no surgery to remove the lens from eyes of adults in which cataracts had developed following vitrectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results according to the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We found no RCTs or quasi-RCTs that had compared surgery versus no surgery to remove the lens from eyes of adults in which cataracts had developed following vitrectomy.

AUTHORS' CONCLUSIONS

There is no evidence from RCTs or quasi-RCTs on which to base clinical recommendations for surgery for postvitrectomy cataract. There is a clear need for RCTs to address this evidence gap. Such trials should stratify participants by their age, the retinal disorder leading to vitrectomy, and the status of the underlying disease process in the contralateral eye. Outcomes assessed in such trials may include changes (both gains and losses) of visual acuity, quality of life, and adverse events such as posterior capsular rupture and retinal detachment. Both short-term (six-month) and long-term (one- or two-year) outcomes should be examined.

Surgical Outcomes of 27-Gauge Pars PLana Vitrectomy for Symptomatic Vitreous Floaters

Purpose

To report the surgical outcomes of 27-gauge pars plana vitrectomy (PPV) for symptomatic vitreous floaters.

Methods

47 eyes of 47 patients (39 males, 83.0%) with symptomatic vitreous floaters who underwent 27-gauge PPV and followed up for more than 6 months were included. The mean age was 34.7 ± 13.5 years.

Results

No operative complication occurred. At first day postoperatively, the intraocular pressure (IOP) was significantly lower than that at other time points (8.6 ± 2.7 mmHg, p < 0.001). 28 (59.6%) eyes had transient hypotony (IOP < 8 mmHg). All were recovered within 1 week postoperatively. The BCVA of 41 eyes (41/47, 87.2%) remained unchanged or improved. Postoperative complications occurred in two eyes: one (2.1%) had endophthalmitis and one (2.1%) had retinal detachment. No clinical significant cataract was observed in the 42 postoperative phakic eyes. 91.5% of the patients were satisfied with the surgery outcome. Besides, 91.3% of the patients felt that the floaters were removed completely or only had an acceptable residual.

Conclusion

Visual acuity of most patients remained unchanged or improved following 27-gague pars plana vitrectomy for symptomatic vitreous floaters, resulting in high patient satisfaction. However, this treatment should be performed with great caution since severe postoperative complications may still occur. This trial is registered with NCT03049163.

Microperimetric Assessment after Epiretinal Membrane Surgery: 4-Year Follow-Up

Purpose. To investigate retinal function using microperimetry in patients affected by idiopathic epiretinal membrane (iERM) and cataract who underwent combined surgery: 4-year follow-up. Design. Prospective, interventional case series. Methods. 30 eyes of 30 consecutive patients with iERM and age-related cataract underwent 25-gauge vitrectomy and cataract surgery. At baseline, 90 and 180 days, and 1 and 4 years, we examined retinal mean sensitivity (MS), retinal mean defect (MD), fixation stability, and frequency of microscotomas using MP1 microperimetry. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) using a spectral domain optical coherence tomography (SD-OCT) were also performed. Results. All patients completed 1-year follow-up, while 23 patients reached last follow-up. Baseline MS and MD (10.48 ± 4.17 and −9.18 ± 4.40 dB) significantly changed at one year (12.33 ± 3.66 and −7.49 ± 3.31 dB, p < 0.01), at four years (14.18 ± 3.46 and −4.66 ± 2.85, p < 0.01), and between one and four years (p < 0.01) after surgery. Compared to baseline, CRT and BCVA significantly changed at one year and remained stable at four years. No variations were observed in fixation stability and frequency of microscotomas compared to baseline. Conclusions. Long-term follow-up using microperimetry seems useful to evaluate patients after iERM surgery: retinal sensitivity changes even when BCVA and CRT remain stable.

Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration

This article aims to facilitate optimal management of cataracts and age-related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer-reviewed English-language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age-related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age-related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low-vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low-vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.

Vitrectomy for floaters: prospective efficacy analyses and retrospective safety profile

PURPOSE

Floaters impact vision but the mechanism is unknown. We hypothesize that floaters reduce contrast sensitivity function, which can be normalized by vitrectomy, and that minimally invasive vitrectomy will have lower incidences of retinal tears (reported at 30%) and cataracts (50-76%).

METHODS

Seventy-six eyes (34 phakic) with floaters were evaluated in 2 separate studies. Floater etiologies were primarily posterior vitreous detachment in 61 of 76 eyes (80%) and myopic vitreopathy in 24 of 76 eyes (32%). Minimally invasive 25G vitrectomy was performed without posterior vitreous detachment induction, leaving anterior vitreous, and using nonhollow probes for cannula extraction. Efficacy was studied prospectively (up to 9 months) in 16 floater cases with Freiburg Acuity Contrast Testing (Weber index [%W] reproducibility = 92.1%) and the National Eye Institute Visual Function Questionnaire. Safety was separately evaluated in 60 other cases followed up on an average of 17.5 months (range, 3-51 months).

RESULTS

Floater eyes had 67% contrast sensitivity function attenuation (4.0 ± 2.3 %W; control subjects = 2.4 ± 0.9 %W, P < 0.013). After vitrectomy, contrast sensitivity function normalized in each case at 1 week (2.0 ± 1.4 %W, P < 0.01) and remained normal at 1 month (2.0 ± 1.0 %W, P < 0.003) and 3 months to 9 months (2.2 ± 1.5 %W, P < 0.018). Visual Function Questionnaire was 28.3% lower in floater patients (73.2 ± 15.6, N = 16) than in age-matched control subjects (93.9 ± 8.0, N = 12, P < 0.001), and postoperatively improved by 29.2% (P < 0.001). In the safety study of 60 floater cases treated with vitrectomy, none developed retinal breaks, infection, or glaucoma after a mean follow-up of 17.5 months. Only 8 of 34 cases (23.5%) required cataract surgery (none younger than 53 years) at an average of 15 months postvitrectomy.

CONCLUSION

Floaters lower contrast sensitivity function, which normalizes after vitrectomy. Visual Function Questionnaire quantified improvement in satisfaction. Not inducing posterior vitreous detachment reduced retinal tear incidence from 30% to 0% (P < 0.007). Postvitrectomy cataract incidence was reduced from 50% to 23.5% (P < 0.02). This approach thus seems effective and safe in alleviating the visual dysfunction induced by floaters.

The relationship between age and the intraoperative complication rate during phacoemulsification surgery

AIM

The aim of this study was to determine if aging is a factor that increases the intraoperative complication rate during phacoemulsification surgery.

MATERIALS AND METHODS

Patients who underwent phacoemulsification surgery were divided into three age groups according to World Health Organization classification, as follows: ≤ 59, 60-74, and ≥ 75 years. The intraoperative complications which occurred during the operation were recorded. Binary logistics regression analysis, Pearson’s correlation analysis, and Duncan’s (multiple range) test were used for statistical analysis.

RESULTS

In total, 789 patients who underwent phacoemulsification surgery at Nigde State Hospital, Ophthalmology Clinic between 01 July 2010 and 31 October 2012 were retrospectively reviewed, and intraoperative complications that occurred during surgery were recorded. Mean age of the patients was 68.98 years (range 38–93 years). In all, 132 (16.7 %) patients were aged ≤ 59 years, 406 (51.5 %) were aged 60 - 74 years, and 251 (31.8 %) were aged ≥ 75 years. The complication rates were 3.78 % in the ≤ 59-year-old age group, 5.17 % in the 60- to 74-year-old age group, and 5.30 % in the ≥ 75-year-old age group. Age did not have a significant effect on intraoperative complication rates during phacoemulsification surgery, according to binary logistic regression analysis (P = 0.58) and Pearson’s correlation analysis (P = 0.076). The incidence and risk of intraoperative complications in the age groups did not differ statistically (Duncan’s test, P = 0.18).

CONCLUSION

Age has no effect on the rate of intraoperative complications during phacoemulsification surgery.

[Successful phacoemulsification in vitrectomized eyes: technical considerations]

Cataract surgery after pars plana vitrectomy significantly improves visual acuity in 85% of cases, limited by retinal comorbidity and surgical complications. However, despite recent advances, this surgery remains a special challenge. Indeed, the surgeon must be aware of its many pitfalls and often adapt his surgical technique to avoid the 10% rate of intraoperative complications reported in the literature - ten times higher than for the non-vitrectomized eye. During the postoperative period, the most common complication is posterior capsule opacification, which may require early laser capsulotomy.

Microincision cataract surgery combined with vitrectomy: a case series

AIM

The objective of this study was to present the results of combined phacovitrectomy using 1.8 mm microincision cataract surgery (MICS) with special emphasis on the anterior segment complications in this group.

METHODS

Retrospective, single-centre case series involving consecutive patients undergoing phacovitrectomy in a single centre in the United Kingdom during a 6-month period.

RESULTS

A total of 52 eyes underwent combined MICS and pars plana vitrectomy. Intraoperative complications included posterior capsule rupture (n=2), minor iris trauma during phacoemulsification (n=1), iatrogenic retinal tears (n=2), and entry site break (n=1). Postoperatively two cases had significant inflammation, one of which resulted in 360° posterior synaechiea, iris bombe, and raised intraocular pressure. Other complications included mild posterior synaechiae (n=2), posterior capsular opacification (n=3), cystoid macular oedema (n=1), and hyphaema (n=1), which spontaneously resolved. There were no cases of intraocular lens decentration. Two patients who underwent surgery for retinal detachment repair subsequently redetached. Among those having surgery for macular hole, non-closure was seen in one patient and one patient developed a retinal detachment.

CONCLUSION

In conclusion, sub-2 mm MICS is a safe and effective technique in dealing with vitreoretinal disorders necessitating cataract surgery at the same time.

20-gauge and 23-gauge phacovitrectomy for idiopathic macular holes: comparison of complications and long-term outcomes

PURPOSE

To assess and compare the complications and long-term visual and anatomical outcomes of 20- and 23-gauge phacovitrectomy (PVT) for idiopathic macular hole repair.

METHODS

A retrospective, consecutive, interventional case series of 72 eyes with idiopathic macular holes were managed with 20-gauge PVT (n=36) or 23-gauge PVT (n=36). All patients underwent a posterior-chamber intra-ocular lens implantation and internal-limiting-membrane peel with the aid of either trypan blue or brilliant blue G(250) dyes.

RESULTS

The macular hole closure rate was 97% with 20-gauge PVT and 100% with 23-gauge PVT. Mean follow-up was 24.06 (±12.83) months with 20-gauge PVT and 17.47 (±5.79) with 23-gauge PVT. Mean visual acuity improvement in LogMar was 0.41 (±0.32) with 20-gauge PVT and 0.52 (±0.25) with 23-gauge PVT (P=0.135). The incidence of retinal breaks was higher with the 20-gauge PVT compared with the 23-gauge PVT, occurring in 13 (36.1%) and 4 (11.1%) cases, respectively (P=0.025). There were no cases of retinal detachment. Postoperative intraocular pressure (IOP), at day 1, was significantly higher with 20-gauge PVT at 24.77 (±12.68) mm Hg compared with 17.20 (±6.95) mm Hg in 23-gauge PVT (P=0.0028). Operating times were longer in 20-gauge PVT at 89.36 (±15.26) min compared with the 23-gauge PVT at 79.33 (±23.82) min (P=0.04).

CONCLUSION

The 20-gauge PVT compared with 23-gauge PVT for macular hole repair is a slightly longer procedure and was associated with an increased incidence of retinal breaks and short-term elevated IOP. Both techniques have comparable visual and anatomical outcomes, but the 23-gauge PVT has advantages with regard to safety profile and operating time.

[Combined phacoemulsification and pars plana vitrectomy]

Cataract is frequently associated with vitreoretinal diseases. Moreover, cataract is also a constant complication of vitrectomy in patients over 50 years. Its occurrence may be very early, especially when internal tamponade is used. For these reasons, a combined procedure including phacoemulsification and vitrectomy accelerates functional rehabilitation of patients, avoiding the need for a second operation. Interventions, their tricks and indications, are described for epimacular membranes, macular holes, diabetic retinopathy and macular hematoma. Combined surgery is a safe and effective procedure whose results are comparable to those of sequential surgery.

Longterm follow-up of pars plana vitrectomy for vitreous floaters: complications, outcomes and patient satisfaction

PURPOSE

Floaters caused by degenerative or postoperative changes in the vitreous can interfere with all aspects of visual functioning. The aim of this study is to report the longterm outcome of pars plana vitrectomy (PPV) for persistent vitreous opacities.

METHODS

In a retrospective, non-randomized, interventional case study we reviewed all cases of vitreous floaters that were vitrectomized at our department between 1997 and 2006. Patient complaints and satisfaction were assessed by a questionnaire administered at the end of follow-up.

RESULTS

Seventy-three consecutive cases were included (61 patients). Mean Snellen best corrected visual acuity (BCVA) before surgery was 0.81. Overall, 85% of patients complained of severe or very severe difficulty caused by floaters. A total of 42% of eyes were pseudophakic, four of which were operated with combined PPV and phacoemulsification. Mean follow-up time was 37 months. Of the phakic eyes, 60% were operated for cataract during follow-up. One retinal detachment (RD) occurred immediately postoperatively (1.3%) and another four eyes developed RD during longterm follow-up 24-44 months after PPV (5.5% of cases). Postoperative BCVA remained mostly unchanged. Overall, 88% of patients were satisfied with the results of the operation.

CONCLUSIONS

Some patients make considerable complaints as a result of vitreous opacities and their distress does not correlate with visual acuity. Vitrectomy is a safe and effective procedure with which to help these patients. Patients should be informed about the risk of cataract progression, unexpected inflammatory reaction and an increased risk for RD several years after PPV (5.5%).

Outcome of phacoemulsification in previously vitrectomized myopic eyes with axial length greater than 26 mm

PURPOSE

To determine the outcome, including the intraoperative and postoperative complications, of phacoemulsification with intraocular lens (IOL) implantation in myopic eyes with axial length of 26 mm or more that had undergone previous pars plana vitrectomy (PPV).

METHODS

This prospective study comprised 37 highly myopic eyes (axial length over 26 mm) with previous vitrectomy that underwent phacoemulsification and were reviewed at a mean postoperative follow-up of 3-6 weeks. The main outcome measures were preoperative and postoperative spherical equivalent, preoperative and postoperative visual acuity, difference between intended and achieved refraction, and any complications during cataract surgery.

RESULTS

The mean age for cataract surgery was 61.5 years. Nuclear sclerosis was present in 91.89% of patients. The mean axial length was 27.53 mm (range 26.03-30.52 mm). The most common indication for vitrectomy in our study was retinal detachment surgery (35 out of 37). Postoperatively, 34 patients (91.89%) had a visual acuity improvement of 2 or more Snellen lines and the best-corrected visual acuity at final refraction was 6/9 (0.2 logMAR) or better in 30 patients (81.08%). Two patients had perioperative complications (5.4%).

CONCLUSIONS

Cataract surgery with IOL implantation can be performed safely in highly myopic eyes after PPV and the final visual acuity outcomes appear to be dependent on the preoperative status of the retina. Our study suggests that the incidence of intraoperative and postoperative complications can be reduced to a minimum with proper planning and meticulous attention to detail during cataract surgery.

The options to minimize the surgical trauma to treat ocular diabetic complications and to improve postoperative recovery and quality of life require an individualized approach

Within the past ten years, small incision pars-plana vitrectomy, and refined microsurgical techniques, together with the introduction of various intravitreally applied drugs, significantly improved the anatomical and functional outcome. Unfortunately many diabetic patients with vitreoretinal complications also have cataract. In diabetic retinopathy, the benefit of simultaneous cataract surgery was long under debate due to possible side effects such as fibrinous reaction or secondary glaucoma. We review recent reports about the results of PPV for complication of diabetic retinopathy and the influence of a simultaneous cataract surgery, that compare different surgical approaches. Pars plana vitrectomy carried out with conventional 0,9 mm incisions (20G PPV) were related to higher incidences of postoperative inflammatory reactions and to a higher frequency of postoperative hypertensive events as compared to small incision vitrectomy (23G PPV). Postoperative recovery was faster in eyes with 23G surgery than after 20G surgery, with no delay by a simultaneous cataract surgery. A 23G-PPV improves the postoperative recovery and the quality of life for the diabetic patient. Cataract is no longer an obstacle for a vitreoretinal surgery. Postoperative recovery is faster and the new technique has less side effects than the conventional technique. In the future, a drug assisted vitrectomy will further reduce the surgical trauma. However, the new options are not equally benefitial for all patients. A further improvement in the quality of life will require a more individualized approach of microsurgical treatment for ocular complications of diabetes.

Idiopathic epiretinal macular membrane and cataract extraction: combined versus consecutive surgery

PURPOSE

To assess the functional and anatomic outcomes of cataract and idiopathic epiretinal macular membrane extraction in combined and consecutive surgeries.

DESIGN

Multicenter, retrospective, comparative case series.

METHODS

One hundred seventy-four patients (174 eyes) with an epiretinal macular membrane (ERM) and cataract were operated on in 1 or 2 sessions in 2 academic centers, Dijon University Hospital and Nancy University Hospital. Combined surgery (n = 109) and consecutive surgery (n = 65) were performed between 2005 and 2006. All patients underwent ERM and internal limiting membrane removal. Cataract extraction was performed with phacoemulsification followed by a posterior chamber intraocular lens implantation. The main outcome measures were near and far visual acuity and central macular thickness evaluated with optical coherence tomography.

RESULTS

After a 12-month follow-up, the postoperative best-corrected visual acuities significantly improved in both the combined and the consecutive surgery groups (near and far vision in both groups, P < .0001). Similarly, the postoperative macular thickness significantly decreased in both groups (P < .0001). We noted no statistical differences between the visual acuity improvement in both groups (near vision, P= .54; far vision, P = .38). However, visual acuity recovery was quicker in the combined surgery group.

CONCLUSIONS

Combined and consecutive surgeries are effective procedures to treat idiopathic ERM. The functional and anatomic results are equivalent in both procedures.