Managing retained lens fragments: raising the bar

Meta-analysis comparing same-day versus delayed vitrectomy clinical outcomes for intravitreal retained lens fragments after age-related cataract surgery

Purpose/design

We aimed to perform a systematic review and meta-analysis comparing the risk difference of clinical outcomes for same-day (SD) vs delayed (DEL) pars plana vitrectomy (PPV).

Methods

We searched MEDLINE (English; January 1, 1985 to July 16, 2013) and article reference lists, for patients with crystalline retained lens fragments and discussion of SD-PPV vs DEL-PPV. For the meta-analysis, articles needed the number of patients receiving SD-PPV and DEL-PPV, and the number, in each group, who experienced one or more of the outcomes: not good visual acuity (VA) (<20/40), bad VA (≤20/200), retinal detachment, increased intraocular pressure/glaucoma, intraocular infection/inflammation, cystoid macular edema, and corneal edema.

Results

Of 304 articles identified, 23 provided data for the meta-analysis. Results were mixed, indicating 1) neither vitrectomy time produced better outcomes in all studies (not good VA risk difference =10.3% [positive numbers favored SD-PPV; negative numbers favored DEL-PPV], 95% confidence interval [CI] = [−0.4% to 21.0%], P=0.059; and bad VA risk difference =−0.3%, 95% CI = [−10.7% to 10.1%], P=0.953); 2) better outcomes with immediate SD-PPV compared with all DEL-PPV (not good VA risk difference =16.2%, 95% CI = [0.8% to 31.5%], P=0.039; and bad VA risk difference =8.5%; 95% CI = [0.8% to 16.2%], P=0.030); and 3) immediate SD-PPV and prompt DEL-PPV (3 to 14 days after cataract surgery) had no significant differences and so may produce similar outcomes (not good VA risk differences range = [−19.9% to 6.5%], 95% CI = [−59.9% to 36.4%]; and bad VA risk differences range = [−6.9% to 7.4%], 95% CI = [−33.1% to 31.8%]).

Conclusion

Perhaps SD-PPV should be limited to facilities at which a vitreoretinal surgeon is immediately available. Otherwise, these results support referring a patient with retained lens fragments promptly to a vitreoretinal surgeon but do not support interfacility transport for SD-PPV.

A retrospective cohort study of clinical outcomes for intravitreal crystalline retained lens fragments after age-related cataract surgery: a comparison of same-day versus delayed vitrectomy

BACKGROUND

This analysis compared outcomes for same-day (under a no-move, no-wait policy) versus delayed vitrectomy for intravitreal crystalline retained lens fragments after surgery for age-related cataract.

METHODS

This was a retrospective, nonrandomized treatment comparison cohort study with a consecutive series of 35 eyes (23 same-day, 12 delayed) receiving both cataract surgery and vitrectomy at the Mayo Clinic Florida between 1999 and 2010. Outcome measures included visual acuity (VA), glaucoma progression, visual utility, and complications. Several techniques (bootstrapping, robust confidence intervals, jackknifing, and a homogeneous sample) were used to reduce selection bias and increase confidence in our small sample's results.

RESULTS

No significant baseline treatment group differences. Mean previtrectomy delay (12 eyes) was 40.9 days (median 29.5, range 1-166). Mean postvitrectomy follow-up (35 eyes) was 47.5 months (median 40.5, range 3.1-123.5). Same-day patients had significantly better final VA (adjusted for age [t = -2.14, P = 0.040] and precataract surgery VA [t = -2.98, P = 0.006]); a higher rate of good final VA (≥20/40), 78.3% (18/23) versus 58.3% (7/12); a lower rate of bad final VA (≤20/200), 4.3% (1/23) versus 25.0% (3/12); and fewer final retinal conditions, 4.3% (1/23) versus 50.0% (6/12). Same-day patients also had marginally significant better mean final VA in the operated eye (20/40 versus 20/90, Z = 1.51, P = 0.130) despite poorer initial VA (20/98 versus 20/75) and higher age (3+ years), better final visual utility, and longer survival times for better VA. Among patients with preexisting glaucoma, same-day patients experienced significantly less differential (operated versus nonoperated eye) glaucoma progression.

CONCLUSION

Results favored same-day patients, who experienced better final VA and visual utility, less differential glaucoma progression, and fewer complications. Results need confirmation with larger samples.

Vitrectomy timing for retained lens fragments after surgery for age-related cataracts: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of vitrectomy timing on outcomes for patients with crystalline retained lens fragments receiving vitrectomy 3+ days after cataract surgery.

DESIGN

Systematic review and meta-analysis of retrospective interventional cases series.

METHODS

Searches of MEDLINE (English, 1/1/85 through 7/30/2010) and article reference lists. Articles were screened for patients with crystalline retained lens fragments after surgery for age-related cataracts, discussion of vitrectomy timing, and, for the meta-analysis, patient totals for at least 1 outcome and multiple time periods, 10+ patients, and mean follow-up ≥3 months. Outcomes included visual acuity, retinal detachment, increased intraocular pressure, intraocular infection/inflammation, cystoid macular edema, and corneal edema. Data extraction was performed twice and quality assessed. Logistic regression estimated study-level odds ratios for each additional 1-week vitrectomy delay. Meta-analysis estimated summary odds ratios using random-effects models.

RESULTS

Of 257 articles identified, there were 43 unique studies (53 articles) for the systematic review, including 27 (31 articles) for the meta-analysis. Early vitrectomies were statistically significantly associated with better outcomes for not good visual acuity (odds ratio: 1.13; 95% CI: 1.04-1.22, P = .005); bad visual acuity (odds ratio: 1.05; 95% CI: 1.01-1.09, P = .009); previtrectomy retinal detachment (odds ratio: 1.29; 95% CI: 1.01-1.65, P = .038); postvitrectomy retinal detachment (odds ratio: 1.13; 95% CI: 1.02-1.26, P = .024); increased intraocular pressure (odds ratio: 1.23; 95% CI: 1.07-1.41, P = .003); and intraocular infection/inflammation (odds ratio: 1.20; 95% CI: 1.01-1.42, P = .041). Results were robust to sensitivity analyses.

CONCLUSIONS

This systematic review and meta-analysis found significantly better outcomes (visual acuity, retinal detachment, increased intraocular pressure, intraocular infection/inflammation) with earlier vitrectomy for retained lens fragments. Reduced vitrectomy delays may yield better patient outcomes.

Retained Lens Fragments: Nucleus Fragments are Associated with Worse Prognosis than Cortex or Epinucleus Fragments

Purpose.

To identify factors that determined the outcome of eyes that underwent pars plana vitrectomy for retained lens fragments after phacoemulsification.

Methods.

A retrospective review of the records of 63 eyes that underwent vitrectomy for retained lens fragments after phacoemulsification. Fragments were defined as nuclear if they contained any nucleus component or non-nuclear if they contained only cortex and epinucleus. Nuclear fragments were further divided into large (at least 1/3 the size of the nucleus) or small.

Results.

A total of 67% of eyes had retained nuclear fragments and 33% had non-nuclear fragments. Of the eyes with nuclear fragments, 64% had large fragments and 36% had small fragments. Statistical analysis revealed that the lens fragment type was the major determinant of the final visual acuity (VA). Only 38.8% (14/36) of the eyes with nuclear fragments achieved final VA of 20/40 or better, compared with 77.7% (14/18) of eyes with non-nuclear fragments (p=0.007). All other parameters, including size of the nuclear fragment, were not correlated with final VA. The major complications encountered in this series were retinal detachment (12.6%), Pseudophakic bullous keratopathy (6.3%), cystoid macular edema (15.8%), and glaucoma (15.8%).

Conclusions.

The major finding of our study is that posterior dislocation of nuclear lens fragments is associated with worse visual outcome than that of non-nuclear fragments. This may be related to a more complicated course of the cataract surgery, direct mechanical damage to the retina, a stronger inflammatory response, or a more traumatic vitrectomy procedure.

Posterior-assisted levitation in cataract surgery

PURPOSE OF REVIEW

Posterior-assisted levitation (PAL) is a surgical maneuver for dealing with rupture of the posterior capsule or zonular dehiscence with threatened or actual subluxation of the nucleus or entire lens into the vitreous during phacoemulsification. PAL is often unknown or overlooked, especially by young or inexperienced surgeons.

RECENT FINDINGS

The advantages of PAL are, first, that it often enables completion of phacoemulsification and intraocular lens placement without conversion to an open eye with nuclear expression and second, it prevents luxation of nucleus, nuclear fragments, or the lens into the vitreous avoiding the necessity for trans pars plana vitrectomy (TPPV)-lensectomy. PAL has recently been criticized by vitreoretinal surgeons as dangerous and to be avoided. However, there is no large series or controlled study showing that the PAL maneuver is associated with an excessive complication rate as compared to cases of nuclear or lens subluxation in the vitreous managed by TPPV-lensectomy with or without previous PAL.

SUMMARY

PAL is a simple technique that can be extremely helpful. In cases in which the PAL maneuver is unsuccessful and in cases with complete luxation of nucleus or lens into the vitreous, the patient should be referred for TPPV-lensectomy.