Posterior chamber intraocular lens implantation during pars plana lensectomy and vitrectomy for diabetic complications

[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.

Advantage of combined procedure in vitreous surgery

Lens preservation facilitates the progression of nuclear cataracts after vitreous surgery among patients over 45 years old, and postoperative nuclear cataracts frequently necessitate intraocular lens surgery. Once the lens is removed, the fundus from the posterior pole to the ciliary process becomes recognizable and surgically reachable, thus making total vitreous removal possible. The complete removal of the incarcerated vitreous to the scleral wound prevents postoperative vitreous base tears, and anterior hyaloidal fibrovascular proliferation. Simultaneous vitreous surgery plus intraocular lens surgery (triple surgery) will prevent these complications before they arise. Triple surgery for patients over 45 years of age is reasonable even if they have amplitude of accommodation, and is an effective surgical strategy in that it improves both the result of the vitreous surgery and the patient's quality of life.

Chirurgie combinée phacoexérèse, vitrectomie et implantation chez le patient diabétique avec phacoémulsification versus phacophragmentation

INTRODUCTION

In diabetic patients, we often need to perform cataract and pars plana vitrectomy. Two different techniques are currently valid: 1) phacoemulsification and pars plana vitrectomy and 2)pars plana lensectomy and posterior vitrectomy.

METHODS

Retrospective study of two different groups of type 2 diabetic patients: those receiving 1) phacoemulsification and pars plana vitrectomy or 2) pars plana lensectomy and posterior vitrectomy.

RESULTS

On statistical analysis there were no differences in complications between the two groups. The effect on visual acuity was similar in both groups.

DISCUSSION

The association of cataract surgery and posterior vitrectomy is a valid technique for treating diabetic retinopathy complications. In the present study, the complications of the two techniques were similar, the most important concerning only anterior chamber opening in the first group.

CONCLUSION

The two techniques of cataract extraction and pars plana vitrectomy at the same time have no differences in their results and are valid for treatment of diabetic patients.

Combined pars plana vitrectomy and phacoemulsification to restore visual acuity in patients with chronic uveitis

PURPOSE

To report the outcomes of combined phacoemulsification and pars plana vitrectomy (PPV) to restore visual acuity in patients with cataract and posterior segment involvement secondary to chronic uveitis.

SETTING

Ocular Immunology and Uveitis Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

METHODS

This study comprised 34 patients (20 women, 14 men; 36 eyes) with posterior segment involvement secondary to chronic uveitis who had combined phacoemulsification and PPV from 1998 to 2002. The main outcome measures were visual acuity, intraocular pressure, and cystoid macular edema.

RESULTS

The mean patient age was 45 years +/- 16.09 (SD). The mean duration of uveitis before surgery was 56 +/- 44.17 months. In 24 eyes (66.7%), an intraocular lens (IOL) was implanted during surgery; 12 eyes (33.3%) were left aphakic. Five eyes (13.8%) received an intraocular steroid injection intraoperatively. Visual acuity improved in 26 eyes (72.2%), deteriorated in 5 (13.9%), and was unchanged in 5 (13.9%). The main reason for decreased visual acuity was refractory macular edema. During the follow-up, 2 IOLs were explanted secondary to lens intolerance. One IOL was repositioned because of iris capture by the haptics, and 1 dislocated inferiorly, causing monocular diplopia. The mean follow-up was 23.4 +/- 16.7 months.

CONCLUSIONS

Results indicate that combined phacoemulsification and PPV is a feasible technique for the removal of cataract and pathologic vitreous in eyes with chronic uveitis. Although the exact role of vitrectomy in patients with uveitis remains to be determined, the combined surgery successfully restored useful vision in most cases.

Foldable versus rigid intraocular lenses in conjunction with pars plana vitrectomy and other vitreoretinal procedures

PURPOSE

To compare the results of foldable acrylic intraocular lens (IOL) implantation through a clear corneal incision with those of rigid IOL implantation in eyes having pars plana vitrectomy (PPV).

SETTING

Tertiary referral-based university institute.

METHODS

A consecutive retrospective comparative chart review was performed in all eyes that had PPV and foldable IOL implantation between May 15, 1999, and November 1, 2000 (n = 30), and all eyes that had PPV and rigid IOL implantation between April 1, 1996, and May 14, 1999 (n = 30). Preoperative baseline data and postoperative outcome data were recorded. Pars plana vitrectomy and associated vitreoretinal procedures were performed as indicated according to individual circumstances. A minimum of 1 week of follow-up information was available for all eyes.

RESULTS

Baseline characteristics in both groups of patients, including age, sex, eye involved, and phakic state, were similar. The preoperative visual acuities were also similar, ranging from 20/30 to hand motions; the mean visual acuity was 20/200. The IOL was implanted in all eyes uneventfully and did not restrict fundoscopy. The mean follow-up was significantly longer in the rigid IOL group (20 months) than in the foldable IOL group (7 months) (P<.001), probably because of the earlier case acquisition. The mean postoperative best corrected visual acuity was 20/200 in the foldable IOL group and 20/100 in the rigid IOL group. There was no difference between the 2 groups in the rate of postoperative retinal detachment, recurrent macular hole, or repeat PPV. Elevated intraocular pressure (IOP) on the first postoperative day was more common in the rigid IOL group than in the foldable IOL group (P =.078) because more patients in the rigid IOL group had surgery for diabetic ocular complications and these patients had a greater IOP rise.

CONCLUSION

Acrylic IOLs can be safely implanted in conjunction with PPV in selected cases.

Unsutured posterior chamber lens implantation in eyes requiring lens extraction at the time of pars plana vitrectomy with silicone oil tamponade

PURPOSE

To describe a technique for the subsequent placement of an unsutured posterior chamber lens intraocular lens (PC IOL) in eyes requiring cataract or clear lens extraction at the time of pars plana vitrectomy (PPV) with silicone oil tamponade.

SETTING

Department of Vitreoretinal Surgery, St. Thomas' Hospital, London, United Kingdom.

METHODS

This retrospective review comprised 25 patients who had phacoemulsification to allow an adequate intraoperative retinal view or adequate access to anterior retinal pathology. Anterior and posterior capsulorhexes were combined with an inferior radial capsulectomy to fashion a keyhole-shaped capsule.

RESULTS

The mean follow-up was 15.9 months +/- 8.0 (SD) (range 3 to 34 months). Silicone oil was removed and IOLs were implanted in 15 eyes (60.0%). Posterior chamber IOLs were implanted in 10 eyes (66.7% of those receiving an IOL), and anterior chamber AC IOLs were implanted in 5 eyes (33.3%). Nine of the 10 eyes receiving a PC IOL (60.0% of all IOLs) had uneventful surgery. In 1 eye, the PC IOL subluxated inferiorly. Two eyes developed pupil block that required further surgery.

CONCLUSIONS

This technique allowed PC IOL implantation in 60% of eyes that received an IOL, showing that in selected patients who require simultaneous lens extraction and silicone oil tamponade, a keyhole-shaped capsulectomy provides for subsequent unsutured PC IOL insertion. The pupil block rate of 8% compares favorably with published rates. Refining the technique may allow it to be used in a greater proportion of eyes that would benefit from safe refractive correction.

Combined phacoemulsification, intraocular lens implantation, and vitrectomy for eyes with coexisting cataract and vitreoretinal pathology

PURPOSE

To report the preoperative, intraoperative, and postoperative outcomes of combining phacoemulsification and posterior chamber intraocular lens (IOL) implantation with pars plana vitrectomy in eyes with significant cataract and coexisting vitreoretinal pathology.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Charts of patients undergoing combined procedures at the Wilmer Ophthalmologic Institute between March 1995 and May 2000 were reviewed.

RESULTS

In all, 122 eyes of 111 patients were identified. Patient ages ranged from 27 to 89 years (mean 65). Forty-three eyes had diabetic retinopathy; 11 had undergone vitrectomy previously. Macular pathology (hole, membrane, choridal neovascularization) was present in 69 eyes. The most common indications for surgery were diabetic vitreous hemorrhage, macular hole, epiretinal membrane, and retinal detachment. In all cases, phacoemulsification and IOL implantation were performed before vitreoretinal surgery. Preoperative vision ranged from 20/30 to light perception and postoperative vision ranged from 20/20 to no light perception. In 105 patients vision improved, in 7 there was no change, and in 10 vision decreased. Postoperative complications included opacification of the posterior capsule, increased intraocular pressure, corneal epithelial defects, vitreous hemorrhage, retinal detachment and iris capture by the IOL.

CONCLUSIONS

Combined surgery is a reasonable alternative in selected patients. Techniques that may simplify surgery and reduce complications include: careful, limited, curvilinear capsulorhexis; in-the-bag placement of IOLs; use of IOLs with larger optics; suturing of cataract wounds before vitrectomy; use of miotics and avoidance of long-acting dilating drops in patients with intravitreal gas; and use of wide-field viewing systems.

Acrylic intraocular lens placement in conjunction with pars plana vitrectomy

PURPOSE

To report the results of placing a foldable acrylic intraocular lens through a clear cornea incision in eyes undergoing pars plana vitrectomy.

METHODS

This interventional case series is a retrospective report of 15 eyes of 15 consecutive patients undergoing foldable (acrylic) intraocular lens insertion in conjunction with pars plana vitrectomy in a single academic institution. Outcome measures included visual acuity and complications.

RESULTS

The intraocular lens was successfully implanted and retained in position in all 15 cases. The intraocular lens did not pose difficulty in examining the fundus or cause any vitreoretinal complications. With mean follow-up of 4.5 months (range, 1--10 months), final median postoperative visual acuity range was 20/200 (range, 20/40--2/200) and consistent with the level of vitreoretinal disease.

CONCLUSION

Acrylic intraocular lenses may be safely implanted in conjunction with pars plana vitrectomy in selected cases.

Epilenticular intraocular lens implantation in traumatic cataract with a ruptured posterior capsule

PURPOSE

To present a case of rapidly progressing traumatic cataract caused by posterior capsule rupture after nonpenetrating ocular injury, as well as a surgical procedure to safely implant the intraocular lens in such a traumatized eye.

METHODS

In a 23-year-old man with traumatic cataract and posterior lens capsule rupture, a one-piece polymethylmethacrylate IOL was implanted before cataract extraction into the ciliary sulcus in front of the cataractous lens. Subsequently, the cataract was removed by pars plana lensectomy.

RESULTS

The surgery and postoperative course were uneventful. Postoperative visual acuity was 20/20.

CONCLUSION

We present a method of intraocular lens implantation in cases of rapidly progressing traumatic cataract caused by posterior capsule rupture after a blunt ocular trauma.

Combined clear corneal phacoemulsification, vitreoretinal surgery, and intraocular lens implantation

PURPOSE

To evaluate the technical feasibility, outcome, and incidence of complications after combined clear corneal phacoemulsification with intraocular lens (IOL) implantation and vitreoretinal surgery.

SETTING

Department of Ophthalmology, Giessen, Germany.

METHODS

The results of combined cataract and vitreoretinal surgery in 38 eyes (36 patients) were retrospectively analyzed. All patients had clinically significant lens opacities and vitreoretinal pathology requiring pars plana vitrectomy. Thirty-seven IOLs were implanted in the capsular bag, and 1 was sulcus fixated.

RESULTS

Postoperatively, visual acuity improved in 20 eyes (52.6%), was unchanged in 16 (42.1%), and was worse in 2 (5.3%). Postoperative complications consisted of anterior chamber fibrin exudation (3 eyes), hyphema (2 eyes), vitreous hemorrhage (1 eye), posterior capsule opacification (16 eyes), neovascular glaucoma (2 eyes), proliferative vitreoretinopathy and redetachment (1 eye), and retinal redetachment after silicone oil removal (1 eye).

CONCLUSION

Compared with 2 separate operations in patients with significant lens opacities and vitreoretinal pathology, combined cataract and vitreoretinal surgery provided more rapid visual rehabilitation. The visual outcome and complications depended primarily on underlying posterior segment pathology and were not related to the combined procedure technique.