Surgical Results of Combined Pars Plana Vitrectomy, Phacoemulsification, and Intraocular Lens Implantation for various Vitreoretinal Diseases

Comparison of pars plana vitrectomy and combined pars plana vitrectomy with phacoemulsification for proliferative diabetic retinopathy: A retrospective study about 120 eyes

PURPOSE

To compare the outcomes of pars plana vitrectomy (PPV) and combined PPV with phacoemulsification (PPVCE) surgeries for proliferative diabetic retinopathy (PDR) and cataract treatment.

METHODS

Retrospective analysis of 120 diabetic patients who underwent PPV or PPVCE.

RESULTS

The key outcome indicators were best-corrected visual acuity (BCVA) and post-operative complications. The PPVCE group had an average age of 53 years, with 50% females and 50% males. The initial visual acuity (VA) was 1.84 log MAR. In this group, BCVA remained stable or increased in 61 eyes (74%). Regarding the PPV group, the average age was 43 years; 65% were men while 34% were women. The initial VA was 1.83 log MAR; in this group, the VA increased or remained stable in 28 eyes (73%). The evolution of the VA was rather symmetric in the two groups without a significant difference (P = 0.9). Similarly, the occurrence of postoperative complications was comparable for the main complications studied, namely the inflammatory reaction (P = 0.809), ocular hypertension (P = 0.344), corneal edema (P = 0.07), and neovascular glaucoma (P = 0.413). However, there was a decrease in BCVA (three lines) in the PPV group after 6 months of follow-up (P = 0.05) in patients with a clear lens preoperatively and who developed a clinically evident cataract.

CONCLUSION

According to this study, for diabetic patients with severe cataracts and vitreoretinal disease requiring vitrectomy, combining vitrectomy with phacoemulsification as a single surgical intervention may be a suitable therapeutic choice. This approach does not significantly increase the risk of visual impairment or retinopathy development.

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.

Silicone Oil Emulsification after Vitrectomy for Rhegmatogenous Retinal Detachment

Purpose

To investigate the characteristics of silicone oil (SO) emulsification after vitrectomy for rhegmatogenous retinal detachment and their possible correlations with clinical factors.

Methods

The first 2 mL of washing out fluid after SO removal was collected, and used for the measurement of the size and number of SO droplets using a Multisizer® 3 Coulter counter (Beckman Coulter, USA). The correlations between SO droplets and clinical factors were analyzed.

Results

A total of 38 patients (23 males, 15 females) who underwent primary PPV with SO injection for RRD and whose retina stayed attached for ≥3 months after SO removal were included in the study. The average number of oil droplets was 1.96 × 10⁶ ± 3.95 × 10⁶/mL (range 0.17 × 10⁶ to 21.71 × 10⁶/ml), and 80.8% (range 64.23%–99.07%) of the droplets were 1-2 μm in diameter. The total number of emulsified SO droplets was not correlated with any clinical factor (all P > 0.05). When the emulsified SO droplets were divided into groups by their diameter, multiple linear regression revealed that age was negatively correlated with the numbers of 5–7-μm in diameter. The total number of emulsified SO droplets was not correlated with any clinical factor (all μm in diameter. The total number of emulsified SO droplets was not correlated with any clinical factor (all P > 0.05). When the emulsified SO droplets were divided into groups by their diameter, multiple linear regression revealed that age was negatively correlated with the numbers of 5–7-μm in diameter. The total number of emulsified SO droplets was not correlated with any clinical factor (all μm in diameter. The total number of emulsified SO droplets was not correlated with any clinical factor (all P > 0.05). When the emulsified SO droplets were divided into groups by their diameter, multiple linear regression revealed that age was negatively correlated with the numbers of 5–7-

Conclusion

Using a Multisizer® Coulter counter, we successfully determined the number and size of SO droplets after emulsification. We found that the number of 5–12-μm-diameter droplets was higher in younger-age patients and was higher in patients using antiglaucoma eyedrops.μm in diameter. The total number of emulsified SO droplets was not correlated with any clinical factor (all

Nd:YAG Capsulotomy after Phacoemulsification in Vitrectomized Eyes: Effects of Pars Plana Vitrectomy on Posterior Capsule Opacification

To compare the progression of posterior capsule opacification (PCO) in patients who required Nd:YAG laser capsulotomy following either combined cataract surgery with pars plana vitrectomy (PPV; C-CV), sequential cataract surgery after PPV (S-CV), or cataract surgery alone (CA). The medical records of 321 patients (408 eyes) who underwent Nd:YAG capsulotomy were retrospectively evaluated. The CA group had a significantly longer time interval from cataract surgery to capsulotomy than that of both the CV group (P = 0.006) and the S-CV (P = 0.013) and C-CV (P = 0.042) subgroups when age-matched comparisons were used. CV patients who implanted a hydrophobic acrylic IOL had shorter time intervals than those of CA patients (P = 0.028). CV patients had larger hazard of earlier capsulotomy than CA patients (hazard ratio (HR) = 1.337; 95% confidence interval (CI) 1.100–1.625; P = 0.004). C-CV and S-CV patients both had larger hazard than CA patients in earlier capsulotomy (HR = 1.304; 95% CI = 1.007–1.688; P = 0.044, HR = 1.361; 95%  CI = 1.084–1.709; P = 0.008, resp.). PCO progresses more rapidly in patients undergoing combined or sequential cataract surgery and PPV than in patients undergoing CA.

Surgical results of combined pars plana vitrectomy and phacoemulsification for vitreous hemorrhage in PDR

Background

The purpose of this study was to evaluate the effectiveness, safety, and incidence of complications after combined clear corneal phacoemulsification with intraocular lens implantation and pars plana vitrectomy in eyes with proliferative diabetic retinopathy coexistent with significant cataract.

Methods

Eighty-five eyes of 85 patients with proliferative diabetic retinopathy underwent primary standard three-port vitrectomy with 20-gauge instruments and phacoemulsification with intraocular lens implantation for vitreous hemorrhage from 2008 to 2011. The main outcome measures were visual outcomes and surgical complications.

Results

Forty patients were male and 45 were female. Their age ranged from 40 to 77 years with a mean of 59.6 years. The mean follow-up was 13 months, with a range of 6–48 months. The preoperative logMAR visual acuity changed from 2.62 ± 0.6 to 0.8 ± 0.7 postoperatively. Postoperatively, visual acuity improved in 79 eyes (92.9%), and did not change in six eyes (7.1%). Intraoperative complications were transient corneal edema (five eyes) and posterior capsular rupture (one eye). Postoperative complications consisted of transient intraocular pressure elevation (25 eyes), corneal epithelial defects (six eyes), anterior chamber reaction (four eyes), hyphema (two eyes), posterior synechiae (four eyes), vitreous hemorrhage (23 eyes), retinal tears (five eyes), retinal detachment (one eye), and neovascular glaucoma (one eye).

Conclusion

Our study suggests that the combined operation of pars plana vitrectomy, phacoemulsification, and intraocular lens implantation is safe and effective for patients with proliferative diabetic retinopathy. We believe that the visual outcome and complications depended primarily on underlying posterior segment pathology and were not related to the combined procedure technique.

Evaluation of an in situ chemically crosslinked hydrogel as a long-term vitreous substitute material

Currently there is no material that can be used as a long-term vitreous substitute, and this remains an unmet clinical need in ophthalmology. In this study, we developed an injectable, in situ chemically crosslinked hydrogel system and evaluated it in a rabbit model. The system consisted of two components, both based on multi-functional poly(ethylene glycol) (PEG) but with complementarily reactive end groups of thiol and active vinyl groups, respectively. The two components are mixed and injected as a solution mixture, react in vivo via the Michael addition route and form a chemically crosslinked hydrogel in situ. The linkages between the end groups and the backbone PEG chains are specially designed to ensure that the final network structure is hydrolysis-resistant. In the rabbit study and with an optimized operation protocol, we demonstrated that the hydrogel indeed formed in situ after injection, and remained transparent and stable during the study period of 9 months without significant adverse reactions. In addition, the hydrogel formed in situ showed rheological properties very similar to the natural vitreous. Therefore, our study demonstrated that this in situ chemically crosslinked PEG gel system is suitable as a potential long-term vitreous substitute.

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.

Posterior capsule opacification following 20- and 23-gauge phacovitrectomy (posterior capsule opacification following phacovitrectomy)

PURPOSE

To compare the development of posterior capsule opacification (PCO) for idiopathic epi-retinal membrane cases between 20- and 23-gauge phacovitrectomy.

METHODS

Cataract surgery of phacoemulsification with the SA60AT implantation and 20- or 23-gauge vitrectomy was performed for 20 patients in both groups. Cataract surgery alone was performed for 50 patients as the control. The PCO density values were measured using Scheimpflug video photography at 1 week, 1, 3, 6, 12, 18, and 24 months after surgery. The number of eyes that required Nd:YAG laser capsulotomy was also examined.

RESULTS

The mean PCO value in the 20-gauge phacovitrectomy group increased significantly with time (P<0.001), whereas those in the 23-gauge phacovitrectomy group and the cataract surgery group did not show any significant change. Furthermore, the PCO value in the 20-gauge phacovitrectomy group was significantly greater than that in the 23-gauge phacovitrectomy group at 6, 12, 18 (P<0.05), and 24 months (P<0.01) after surgery. The PCO value in the 23-gauge phacovitrectomy group was significantly greater than that in the cataract surgery group 24 months after surgery (P<0.05). The rate of capsulotomy in the 20-gauge phacovitrectomy group was significantly higher than that in the cataract surgery group (P=0.007), whereas there was no significant difference between the 23-gauge phacovitrectomy group and the cataract surgery group.

CONCLUSION

PCO rate in eyes with the 23-gauge phacovitrectomy was lower than in those with the 20-gauge phacovitrectomy, and PCO rate even in the 23-gauge phacovitrectomy was higher than in those with cataract surgery.

Anterior Segment Complications after Phacovitrectomy in Diabetic and Nondiabetic Patients

Purpose.

To evaluate early and late postoperative anterior segment complications of phacovitrectomy and foldable intraocular lens (IOL) implantation in eyes with cataract and coexisting vitreoretinal disease in diabetic and nondiabetic patients.

Setting.

Department of Ophthalmology, Baskent University Hospital, Ankara, Turkey.

Methods.

The records of 189 consecutive patients with cataract and posterior segment pathology necessitating phacovitrectomy were retrospectively analyzed. Patient profile, indications for surgery, preoperative findings, intraoperative and postoperative course, and postoperative outcome were evaluated. Phacoemulsification was performed through a clear corneal incision with IOL implantation prior to 23-G pars plana vitrectomy.

Results.

There were 97 (51.3%) diabetic and 92 (48.6%) nondiabetic patients. The most common indications for surgery were vitreous hemorrhage (57; 58.7%), tractional detachment (35; 36%), and premacular hemorrhage (5; 5.1%) in diabetic patients, and rhegmatogenous retinal detachment (40; 43.4%), macular hole (22; 23.9%), epiretinal membrane (20; 21.7%), and vitreomacular traction (10; 10.8%) in nondiabetic patients. Early (within 4 weeks) postoperative complications included elevation of intraocular pressure, fibrinous uveitis, corneal edema, and development of posterior synechia. Long-term (after 4 weeks) complications included migration of silicone oil into the anterior chamber, posterior capsule opacification, and decentered IOL. The ratio of fibrinous uveitis, posterior synechia, and posterior capsule opacification was found higher in the diabetic group (all p<0.05).

Conclusions.

Combined vitreoretinal surgery and phacoemulsification is safe and effective in treating vitreoretinal abnormalities coexisting with cataract in diabetic and nondiabetic patients. Diabetic patients should be monitored more carefully for fibrinous uveitis and posterior synechia in the early postoperative period and for posterior capsular opacification in the late postoperative period.

The incidence and distribution of iatrogenic retinal tears in 20-gauge and 23-gauge vitrectomy

PURPOSE

The development of 23-gauge vitrectomy surgery has many benefits including a reduction in surgical time and faster postoperative rehabilitation; however, some have suggested that the complication rate is higher. To assess this we compared the incidence and distribution of iatrogenic retinal tears in 20- and 23-gauge surgery.

METHODS

Fifty consecutive 23-gauge and 50 consecutive 20-gauge vitrectomy cases were selected; eyes with a history of previous vitreoretinal surgery were excluded. All surgery was performed by two surgeons (JL and RN). Entry-site breaks (ESB) were defined as any new vitreoretinal abnormality occurring within 1 clock hour of an entry site for which treatment with cryotherapy was deemed necessary. Data were collected by retrospective case note review. Statistical analysis was carried out using Fisher's exact and χ(2)-tests.

RESULTS

ESB occurred in 24% (12/50) of cases in the 20-gauge group compared with 8% (4/50) in the 23-gauge group (P = 0.03); 88% (14/16) occurred superiorly on the same side as the surgeons' dominant hand. Iatrogenic breaks recorded elsewhere indicated an increased incidence in the 20-gauge group (9/50 compared with 6/50 in 23-gauge) but this did not achieve significance; the most common position was at 6 o'clock.

CONCLUSIONS

23-Gauge vitrectomy is associated with significantly fewer ESB when compared with conventional 20-gauge vitrectomy. The incidence of other iatrogenic breaks did not appear to be significantly different between the two groups.

Improving intraocular lens power prediction in combined phacoemulsification and vitrectomy in eyes with macular oedema

PURPOSE

To report the accuracy of intraocular lens (IOL) power estimation in eyes that have undergone phacovitrectomy for retinal diseases with accompanying macular oedema.

METHODS

A retrospective study was conducted in 23 eyes of 23 patients at Soonchunhyang University Hospital, Seoul, Korea. The relationship between preoperative planned refraction and postoperative achieved refraction was evaluated by simple linear regression analysis. Pre- and postoperative macular thicknesses were measured using optical coherence tomography (OCT). The estimated IOL power of the ultrasound axial length (AL) and the adjusted AL (increased amount of macular thickness added to ultrasound AL) were compared using a paired t-test.

RESULTS

The pre- and postoperative refractions were -0.28 ± 0.14 dioptres (D) and -0.74 ± 0.48 D, respectively (P = 0.000). The postoperative refraction showed better correlation with the target refraction of the implanted IOL calculated with the adjusted AL (R = 0.608, P = 0.002) compared with the original planned refraction (R = 0.142, P = 0.518). The IOL power calculated with the adjusted AL was 0.59 ± 0.56 D less than the original IOL power (P = 0.000).

CONCLUSION

Postoperative myopic shift can be corrected by adding the amount of macular thickness measured on OCT to the ultrasound AL, or by simply implanting an IOL 0.50 D less than the IOL targeted for emmetropia.

Factors contributing to posterior capsule opacification following 23-gauge transconjunctival phacovitrectomy

BACKGROUND AND OBJECTIVE

To determine posterior capsule opacification (PCO) rate and identify contributory factors in a series of patients undergoing combined 23-gauge transconjunctival phacovitrectomy.

PATIENTS AND METHODS

Retrospective data on 221 consecutive patients operated on by a single senior surgeon using a standard technique were collected and subjected to univariate analysis with chi-square tests and multivariate analysis with logistic regression.

RESULTS

PCO developed in 46 of 221 cases (20.8%). Major risk factors were: rhegmatogenous retinal detachment (relative risk = 3.3, P = .002), axial length greater than 24.5 mm (relative risk = 2.0, P = .093), intraoperative/postoperative complications (relative risk = 3.3, P = .04), C2F6 tamponade (versus SF6/air) (relative risk = 2.8, P = .01), and postoperative posturing (relative risk = 4.1, P < .001). Multiple logistic regression analysis showed the latter two to be most important.

CONCLUSION

PCO rate following 23-gauge phacovitrectomy is lower than most rates reported for 20-gauge phacovitrectomy. Using shorter-acting gas tamponade and avoiding postoperative posturing may help lower PCO rates.

The results of B-scan ultrasonography in different positions after vitrectomy and gas tamponade

Purpose

To determine the proper time frame in which to assess retinal attachment status and to evaluate the superior retinal attachment status by performing B-scan ultrasonography in different positions on patients who have undergone pars plana vitrectomy and gas tamoponade.

Methods

In this prospective study, 23 patients (23 eyes) who had undergone pars plana vitrectomy and gas tamponade were investigated between June 2005 and February 2006. SF₆ (18%) was injected into the vitreous cavity of 15 eyes, and C₃F₈ (14%) was injected into the vitreous cavity of 8 eyes. At postoperative day 1, day 3, week 1, week 2, and week 4, B-scan ultrasonography was performed in the supine, sitting, prone, right decubitus, and left decubitus positions.

Results

The proper time to evaluate the retinal attachment status was three days post-operatively in 10 eyes (66.7%) with SF₆ (18%) injections and two weeks post-operatively in six eyes (75%) that had C₃F₈ (14%) injections. The superior retinal attachment status can be evaluated from the summation of B-scan ultrasonography results performed in the right decubitus and left ducubitus positions.

Conclusions

The proper time to evaluate the retinal attachment status was related to the degree of the gas absorption when performing B-scan ultrasonography after pars plana vitrectomy and gas tamponade. To evaluate the entire retina, it is useful to perform B-scan ultrasonograhy in the prone, right decubitus and left decubitus positions.