Posterior chamber intraocular lens insertion during pars plana lensectomy and vitrectomy for complications of proliferative diabetic retinopathy

Refractive Outcomes of Combined Cataract Surgery and Vitrectomy Compared to Cataract Surgery Alone

PURPOSE

The aim of the study was to evaluate the refractive outcomes of combined cataract surgery and vitrectomy compared to cataract surgery alone.

METHODS

This retrospective chart review study included two groups: (1) combined surgery in 103 eyes (101 patients) who underwent cataract surgery with posterior chamber intraocular lens (PCIOL) placement by a single cataract surgeon and vitrectomy by a single vitreoretinal surgeon at the same surgical setting; (2) cataract surgery alone by the same surgeon in 107 eyes (84 patients). Refractive outcomes and complications between the combined and cataract surgery alone group were compared. The predicted refractive error was compared to postoperative refractive outcomes in both groups, surgically induced astigmatism (SIA), intraoperative or postoperative complications of either cataract surgery or vitrectomy, and cystoid macular edema.

RESULTS

There was no statistically significant difference between predicted and actual postoperative refractive outcomes between the combined and cataract surgery alone groups (within ±0.5 diopters [D], p = 0.099; within ±1.0 D, p = 0.721). There was no difference in SIA refractive outcomes between the two groups (p = 0.509). The use of intraoperative gas for retina tamponade did not significantly affect postoperative refractive outcomes. Both cataract surgery and vitrectomy were successfully performed without unexpected complications from either procedure affecting the other.

DISCUSSION/CONCLUSION

Combined cataract surgery and vitrectomy allows excellent refractive outcomes equal to cataract surgery alone, allowing each procedure to be performed independently by separate anterior and posterior segment surgeons. Combined procedures can be performed in eyes with a variety of retinal indications and can include fluid-gas exchange with minimal risk of PCIOL malposition or change in targeted refraction.

Combining cataract surgery with 25-gauge high-speed pars plana vitrectomy: A prospective study

PURPOSE

To compare visual outcome and postoperative complications of combined 25-gauge pars plana vitrectomy and phacoemulsification with vitrectomy alone surgery in patients with epiretinal membrane and macular hole.

METHODS

A total of 110 eyes (73 eyes with epiretinal membrane and 37 eyes with macular hole) were enrolled in this prospective study. The eyes were divided into two groups: Group A included 55 eyes which underwent phacovitrectomy at the same time and Group B included 55 eyes which underwent vitrectomy alone. Follow-up visits were at 1, 3, and 6 months.

RESULTS

The best-corrected visual acuity correlation by analysis of variance measurement showed statistically non-significant differences between the two groups (p = 0.32). The post hoc analysis from baseline, 1°, 2°, and 3° follow-ups was not statistically significant (p > 0.05). The most common postoperative complication was cystoid macular edema that has been detected in 11 patients (10%) (seven eyes in Group A and four eyes in Group B): 2 patients (1.8%) developed a chronic macular edema. Intraocular hypertension occurred in five eyes (4.5%) (three in Group A and two in Group B). Four eyes (3.6%) underwent another surgical procedure for a persistent macular hole (two in Group A and two in Group B). The intraocular lens repositioning was performed one day after surgery in three eyes (2.7%) (Group A). The mean preoperative visual acuity was not different between the two groups (p = 0.80).

CONCLUSION

No significative differences between combined surgery and vitrectomy alone have been detected, in terms of postoperative complications and visual outcome.

Predictors of postoperative bleeding after vitrectomy for vitreous hemorrhage in patients with diabetic retinopathy

AIMS/INTRODUCTION

To clarify the association between perioperative variables and postoperative bleeding in pars plana vitrectomy for vitreous hemorrhage in diabetic retinopathy.

MATERIALS AND METHODS

The present retrospective study enrolled 72 eyes of 64 patients who were admitted to Osaka University Hospital between April 2010 and March 2014, and underwent vitrectomy for vitreous hemorrhage as a result of diabetic retinopathy.

RESULTS

Postoperative bleeding developed in 12 eyes. Using binomial logistic regression analysis, we found that the duration of operation was the only significant variable associated with postoperative bleeding within 12 weeks after vitrectomy. Furthermore, Poisson regression analysis identified fasting blood glucose just before vitrectomy, no treatment with antiplatelet drugs and treatment with antihypertensive drugs, as well as duration of operation, to be significantly associated with the frequency of bleeding within 52 weeks after vitrectomy.

CONCLUSIONS

Long duration of operation can be used to predict bleeding within both 12 and 52 weeks after vitrectomy. In addition, fasting blood glucose just before vitrectomy, no treatment with antiplatelet drugs and treatment with antihypertensive drugs might be risk factors for postoperative bleeding up to 1 year after vitrectomy.

Choice of Surgical Technique in the Management of Cataract Combined with Vitreous Surgery

Purpose.

To compare different methods of lens removal during vitreous surgery.

Methods.

We reviewed the data of 37 consecutive eye operations with combined surgery of the lens and vitreous in the Mülheim Eye Hospital between March ‘93 and September ‘94.

Results.

In 14 eyes a pars plana lensectomy was done, in 7 an ECCE (extra capsular cataract extraction), and in 16 phacoemulsification was combined with a regular threeport pars plana vitrectomy.

Conclusions.

The choice of procedure was mainly influenced by the hardness of the lens and whether an IOL implant was considered. If no IOL is planned and the lens is soft enough, the best way to remove it is by pars plana lensectomy. If the nucleus seems too hard, phacoemulsification should be performed, because of the risk of releasing the nucleus into the posterior segment. If an IOL is planned, the best method of lens removal is phacoemulsification via a scleral tunnel. In both cases if the nucleus is very hard ECCE should be performed because of the risk of corneal edema.

The outcomes and prognostic factors of vitrectomy in chronic diabetic traction macular detachment

Purpose

To investigate the outcomes of pars plana vitrectomy (PPV) for chronic diabetic traction macular detachment (CTMD).

Methods

Ninety-six eyes that underwent PPV for CTMD of at least 6 months duration were retrospectively analyzed. Retinal reattachment rate, final vision, and prognostic factors for poor visual outcome were the main outcome measures.

Results

All eyes had long-standing TMD (median 12, range: 6–70 months). The median postoperative follow-up was 15 (range: 3–65) months. Eighty-seven eyes (90.6%) had their retina and macula reattached after one PPV. At final examination, 84 eyes (87.5%) had stable vision or at least one line improvement, and three had no light perception. Seventeen (17.7%) and 41 (43%) eyes had preoperative visual acuity of ≥20/200 and ≥5/200 as compared to 40 (41.6%; P=0.0005) and 64 (66.7%; P=0.0014) eyes at final follow-up, respectively. Age >50 years (Odds ratio [OR] =5.84, 95% confidence interval [CI] =1.53–22.19, P=0.01), preoperative vision <20/400 (OR =7.012, 95% CI =1.82–26.93, P=0.005), and ischemic macula (OR =14.13, 95% CI =3.61–55.33, P<0.001) were significantly associated with final vision <20/400.

Conclusion

PPV for CTMD may be beneficial particularly in patients who are relatively younger and have good baseline vision and no macular ischemia.

Combined 23-gauge vitrectomy and femtosecond laser-assisted cataract surgery

BACKGROUND

The aim of this study was to assess the safety and surgical results of femtosecond laser-assisted phacovitrectomy.

METHODS

A retrospective analysis of the medical records of patients over 50 years of age with vitreoretinal pathology, who had undergone pars plana vitrectomy using 23-gauge instruments and femtosecond laser-assisted cataract surgery and implantation of an intraocular lens, was performed at the Instituto de Microcirugía Ocular between June 2012 and September 2013. The diameter of the anterior capsulorhexis was set at 4.8 mm in cases where a gas tamponade was used and at 5 mm in all other cases. During the pars plana vitrectomy, posterior capsulotomy was performed on all eyes. An assessment was carried out of preoperative characteristics, surgical indications, postoperative results and complications. Only patients with a minimum of 3 months of follow-up were included.

RESULTS

A total of 21 eyes in 21 patients (71.4% women) were treated. Mean age (± SD) was 65.8 ± 6.4 years (range 53-76). The most common indication for surgery was epiretinal membrane (61.9%), followed by vitreous haemorrhage (23.8%) and macular hole (14.3%). The mean preoperative best corrected visual acuity (BCVA) was 0.81 ± 1.01 logMAR and the mean postoperative BCVA was 0.12 ± 0.19 logMAR (p = 0.003). 85.7% of patients improved their visual acuity. The remaining patients maintained their visual acuity. The only intraoperative complication related to femtosecond laser was 1 case of suction loss (4.8%). A patient with rhegmatogenous retinal detachment discovered during surgery required an additional circular scleral procedure and developed synechiaes in the early postoperative period (<1 month). There were no cases of subluxation of the intraocular lens. Mean follow-up was 6 months (range 3-14).

CONCLUSIONS

The application of femtosecond laser in phacovitrectomy is a safe and effective technique that presents advantages compared to conventional techniques in cases of macular pathology and/or vitreous haemorrhage.

Intraoperative intravitreal triamcinolone decreases macular edema after vitrectomy with phacoemulsification

Background

The purpose of this study was to evaluate the incidence and amount of macular edema by optical coherence tomography (OCT) after combined small gauge sutureless vitrectomy with phacoemulsification and intravitreal triamcinolone.

Methods

This retrospective case series included 194 consecutive eyes undergoing nonemergent vitrectomy with phacoemulsification and intravitreal triamcinolone. Ninety-one eyes had preoperative and postoperative OCT available and were included in the analysis. The eyes were evaluated for retinal thickness with preoperative and postoperative OCT, and for preoperative and postoperative best-corrected visual acuity. The main outcome measures were retinal thickness, OCT appearance, and best-corrected visual acuity.

Results

The incidence of macular edema in all eyes preoperatively was 64.8% and postoperatively was 50.5%. Mean central subfield and center point thickness in eyes with macular edema preoperatively were 361 μm and 349 μm, respectively, and postoperatively were 315 μm and 304 μm, respectively. In eyes without preoperative macular edema, mean preoperative central subfield and center point thickness were, respectively, 210 μm and 181 μm versus 220 μm and 192 μm postoperatively. Best corrected visual acuity improved from 20/190 preoperatively to 20/150 at postoperative month 1 and 20/110 at month 6. Postoperative intraocular pressure ≥ 25 mmHg was observed in 7.7% of eyes, none of which required surgical intervention for steroid-induced glaucoma.

Conclusion

Use of intravitreal triamcinolone with combined vitrectomy and phacoemulsification may play an important role in modulating postoperative macular edema. Adverse pressure rise is infrequent and usually limited.

Ocular hypertension after intravitreal triamcinolone with vitrectomy and phacoemulsification

OBJECTIVE

To evaluate the effect of adjunctive intravitreal triamcinolone (IVTA) on intraocular pressure (IOP) in the setting of combined vitrectomy with phacoemulsification.

DESIGN

Retrospective case series.

PARTICIPANTS

One hundred thirty-one consecutive eyes undergoing nonemergent vitrectomy with phacoemulsification and IVTA were reviewed and included in the analysis. All 131 eyes received 4 mg IVTA at the end of surgery.

METHODS

Pre-and postoperative IOP, use of pressure-lowering medications, and rate of glaucoma surgery were analyzed. Pre-operative risk factors were analyzed.

MAIN OUTCOME MEASURES

IOP, glaucoma medications, or glaucoma surgery.

RESULTS

Secondary ocular hypertension (defined as IOP ≥ 25 mmHg) was found in 28 eyes (21%), the majority during postoperative day 1 only. Twelve eyes (9%) had an elevated IOP measurement noted at a visit after the first postoperative day. Five (4%) had an IOP rise of ≥10 mmHg over baseline at any time after postoperative day 1. Six (5%) required glaucoma medications. One eye required a glaucoma drainage implant for diabetic neovascular angle closure glaucoma, and one eye required enucleation for intractable neovascular glaucoma due to radiation retinopathy. Elevated postoperative IOP was statistically associated with higher baseline IOP and presence of preoperative glaucoma.

CONCLUSIONS

Therapeutic intravitreal triamcinolone with combined vitrectomy and phacoemulsification causes infrequent and usually mild secondary ocular hypertension. Secondary ocular hypertension is associated with preoperative glaucoma and high IOP.

Combined pars plana vitrectomy and lens management in complex vitreoretinal disease

Concurrent cataract and vitreoretinal disorders are relatively common. Additionally, a considerable number of phakic eyes develop visually significant cataract following pars plana vitrectomy. The ophthalmic literature is replete with reports of a combined procedure consisting of simultaneous cataract extraction, intraocular lens implantation, and pars plana vitrectomy to treat a wide range of vitreoretinal disorders and co-existing cataracts. Historical concerns of increased risk of complications with the combined procedure have been shown not to be clinically significant. The combined procedure offers the advantages of a single procedure, including faster recovery time and cost effectiveness. Earlier reports of the combined procedure describe pars plana lensectomy and extracapsular cataract extraction as techniques for cataract extraction. Currently, phacoemulsification with implantation of a foldable posterior intraocular lens implantation has become the preferred technique of cataract removal. With advances in instrumentation and surgical techniques, the combined procedure offers a safe and effective way to manage concurrent cataract and complex vitreoretinal disease.

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.

Modified anterior capsulotomy technique and histopathology of the anterior capsule in cataracts after prolonged exposure to intravitreal silicone oil

Cataract development is common in phakic eyes after pars plana vitrectomy and exposure to silicone oil. Anterior capsule rigidity is frequently encountered during cataract surgery in these cases. We report a capsulotomy technique to overcome capsule rigidity, as well as the histopathological findings of the anterior capsule after prolonged exposure to silicone oil.

Surgical results of triamcinolone assisted pars plana vitrectomy combined with phacoemulsification in diabetic patients

Purpose:

It is aimed to evaluate the technical feasibility, safety, outcome, and incidence of complications after clear corneal phacoemulsification with foldable intraocular lens implantation (IOL) and triamcinolone assisted pars plana vitrectomy in patients with proliferative diabetic retinopathy.

Methods:

The results of combined phacoemulsification, in the capsular bag foldable intraocular lens implantation and triamcinolone assisted pars plana vitrectomy in 75 eyes of 72 patients, were retrospectively evaluated. Surgery was performed using general anesthesia in 9 cases, and monitored retrobulbar block in 66 cases. In all cases, phacoemulsification with clear corneal incision and foldable acrylic IOL implantation were performed before vitreoretinal surgery. The main investigation points were preoperative and postoperative best corrected visual acuity (BCVA), and intraoperative and postoperative complications.

Results:

The mean age at surgery was 62.07 ± 9.51 years (range 22 to 78 years) and the postoperative follow-up time was 17.17 ± 7.25 months. All eyes had clinically significant cataract that interfered with visualization of the retina preoperatively. All eyes had proliferative diabetic retinopathy. Postoperatively, visual acuity improved in 65 eyes (86.7%), was unchanged in 9 eyes (12.0%), and decreased in 1 eye (1.3%). The most postoperative complications consisted of a mild iritis in 8 eyes (10.7%), recurrent vitreous hemorrhage in 8 eyes (10.7%), posterior capsule opacification in 7 eyes (9.3%), transient intraocular pressure increase in 6 (8.0%), iatrogenic retinal tear in 6 (8.0%), epiretinal membrane in 5 (6.7%).

Conclusion:

The results of combined phacoemulsification in the capsular bag foldable IOL implantation and triamcinolone assisted pars plana vitrectomy show that visual acuity outcomes are generally favorable and complications are acceptable in diabetic patients. Visual results and complications depend primarily on the underlying posterior segment pathology. The use of triamcinolone acetonide may simplify surgery and decreases the postoperative inflammation.

Combined lensectomy, vitrectomy, and primary intraocular lens implantation in patients with traumatic eye injury

PURPOSE

To analyse the postoperative anatomic and functional outcomes in addition to complications after combined lensectomy, vitrectomy, and primary intraocular lens (IOL) implantation in patients with traumatic eye injury.

METHODS

Retrospective review of patients with traumatic cataract and posterior segment injury who underwent combined lensectomy, vitrectomy, and primary IOL implantation with a minimum follow up (FU) of 3 months.

RESULTS

Thirteen consecutive patients (all male) with a mean age of 42.8 years (range 17-82 years) underwent combined lensectomy, vitrectomy, and primary IOL implantation from February 2000 to January 2006. Postoperative FU ranged from 3 to 54 months (mean 17.6 months). Best corrected visual acuity (BCVA) at presentation ranged from 20/30 to hand movement and was worse than 20/200 in eight patients (61%). Four patients (31%) had blunt trauma with no globe rupture. Of the nine patients (69%) with a penetrating eye injury (PEI), eight had an intraocular foreign body (IOFB) with one retinal detachment at presentation. Four patients had primary closure at the time of the vitrectomy. All eight IOFBs were removed. Seven patients had additional scleral buckling and four intravitreal gas injection. BCVA at last FU ranged from 20/20 to 20/300 and was 20/40 or better in eight eyes (62%). All patients had an attached retina at last FU. One eye had further surgery for epiretinal membrane proliferation and ptosis.

CONCLUSIONS

These results suggest that combined vitrectomy, lensectomy and primary intraocular implantation can offer good visual rehabilitation in patients with traumatic cataract and posterior segment injury.

Bimanual microphacoemulsification and Acri.Smart intraocular lens implantation combined with vitreoretinal surgery

PURPOSE

To assess the efficacy and safety of bimanual microphacoemulsification combined with vitrectomy in eyes with clinically evident cataract and vitreoretinal pathology.

SETTING

Institute of Ophthalmology of the University of Modena and Reggio Emilia, Modena, Italy.

METHODS

This prospective case series comprised 19 consecutive patients with clinically significant cataract who were scheduled for vitrectomy. Bimanual microphacoemulsification was performed, and an Acri. Smart 46 S hydrophobic acrylic intraocular lens (IOL) with a 6.0 mm optic (Acri.Tec, Inc.) was implanted in the capsular bag. Immediately after, standard 3-port vitrectomy was performed.

RESULTS

The prevailing vitreoretinal pathology was retinal detachment, with 1 case of macular pucker and 1 case of macular hole. In all cases, the IOL was implanted in the capsular bag. There were no intraoperative complications during the cataract surgery or vitrectomy. Follow-up 1, 15, 30, 90, and 180 days after surgery showed significant visual recovery in all cases. The mean endothelial loss was 10.05%+/-2.01% (SD). In 3 cases that had tamponade with heavy silicone oil, progressive posterior capsule opacification occurred 6 months after surgery.

CONCLUSIONS

Bimanual microphacoemulsification combined with vitrectomy was effective and safe. The microincisions and 19-gauge instruments provided excellent chamber resistance that simplified surgical maneuvers in eyes that might have a distorted fundus reflection and increased zonular laxity. The Acri. Smart 46 S IOL, which can be injected through a 2.0 mm incision, provided good fundus visibility during vitrectomy and good maneuverability up to the extreme periphery without resulting in glare or distracting reflections for the surgeon.

Tilt and decentration of the intraocular lens following combined vitrectomy and pars plana lensectomy

PURPOSE

To investigate intraocular lens (IOL) tilt and decentration following combined vitrectomy and pars plana lensectomy (PPL) with IOL implantation in patients with proliferative diabetic retinopathy.

METHODS

We followed 25 patients with proliferative diabetic retinopathy who underwent PPL and IOL (MA60BM) implantation at the time of pars plana vitrectomy (PPL group), and 25 patients who underwent phacoemulsification and IOL (MA60BM) implantation without vitrectomy (PE group). Intraocular lens tilt and decentration were evaluated quantitatively, using the anterior eye segment analysis system, approximately 12 months after surgery.

RESULTS

There was no significant difference in IOL tilt (p = 0.47) or decentration (p = 0.26) between the PPL and PE groups.

CONCLUSIONS

The present study suggests that tilt and decentration of the IOL are acceptable in combined vitrectomy and pars plana lensectomy.

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 phacoemulsification and pars plana vitrectomy for macular hole treatment

PURPOSE

To assess the outcome of simultaneous phacoemulsification, pars plana vitrectomy and intraocular lens (IOL) implantation in eyes with macular hole.

METHODS

A retrospective study was conducted in 38 eyes (36 patients) after combined phacoemulsification, insertion of a posterior capsule IOL and pars plana vitrectomy.

RESULTS

The macular hole was successfully closed in 32 of the 38 eyes (84%). In six eyes (16%) the hole failed to close and one eye underwent a second operation. Vision improved by two or more Snellen lines in 29 eyes (73%), there was no change in seven eyes (18%), and visual acuity decreased in two eyes (5%). Intraoperative and postoperative complications included retinal tears in nine eyes (24%), posterior capsule rupture in two eyes (5%), transient postoperative increase of intraocular pressure in eight eyes (21%), and posterior capsule opacification in five eyes (13%).

CONCLUSION

Combining phacoemulsification, IOL insertion and pars plana vitrectomy for macular hole repair can reduce the need for cataract surgery in the future, decrease costs, shorten postoperative recovery time and allow for clearer intraoperative visualization, making the procedure safer and more effective.

Chirurgische Therapie der diabetischen Retinopathie und Makulopathie

Surgical therapy of diabetic retinopathy has been refined since the Early Treatment Diabetic Retinopathy Study (ETDRS). ETDRS did not perform panretinal photocoagulation at the time of surgery, which is currently considered a major part of vitrectomy, e.g., in vitreous hemorrhage. Despite improved surgical techniques, patient expectations and surgical outcome still differ considerably in severe cases of proliferative diabetic retinopathy. In this review of the literature we discuss the current surgical options and indications in diabetic retinopathy and maculopathy.

Phacoemulsification and foldable intraocular lens implantation combined with vitrectomy and silicone oil tamponade for severe proliferative diabetic retinopathy

PURPOSE

To determine the clinical outcomes of phacoemulsification and foldable intraocular lens (IOL) implantation combined with primary vitrectomy and silicone oil tamponade to treat severe proliferative diabetic retinopathy (PDR).

SETTING

Department of Ophthalmology, Seoul National University College of Medicine, and Seoul Artificial Eye Center, Seoul National University Hospital Clinical Research Institute, Seoul, Korea.

METHODS

The results of combined cataract surgery and silicone oil injection in 20 eyes (20 patients) were retrospectively analyzed. All patients had tractional or tractional-rhegmatogenous retinal detachment and clinically significant lens opacities; none had previous intraocular surgery. An acrylic foldable IOL was implanted in the capsular bag or ciliary sulcus.

RESULTS

Primary anatomic success was achieved in 90% of eyes. Functional success was attained in 60% of eyes after a mean follow-up of 7.6 months. The postoperative visual acuity improved in 60% of patients, was unchanged in 20%, and was worse in 20%. Silicone oil was removed in 80% of patients without complications after a mean of 3.4 months. The mean absolute value of the difference between the predicted refraction and postoperative refraction was 0.74 diopter (D) (range 0.03 to 1.74 D).

CONCLUSION

Phacoemulsification and foldable IOL implantation combined with primary vitrectomy and silicone oil tamponade was performed safely with favorable anatomic and visual outcomes in eyes with severe PDR.

INCIDENCE OF CATARACT EXTRACTION AFTER DIABETIC VITRECTOMY

PURPOSE

To determine the frequency of visually significant cataracts after vitrectomy for complications of diabetic retinopathy.

METHODS

We studied 40 patients and 56 concurrent control patients in a retrospective, consecutive, comparative case series in an institutional setting. Entry criteria included phakic patients with a clear lens or mild lens opacity undergoing anatomically successful diabetic vitrectomy, without lens removal at the time of vitrectomy, without intraocular gas or silicone oil use, and with at least 1 year of postoperative follow-up examination information. Two comparative phakic control groups with the diagnosis of macular hole or epiretinal membrane were selected, also with follow-up examination information of at least 1 year postoperatively. The occurrence of cataract extraction was the principal outcome measure. Its validity as a measure of cataract formation was evaluated by ascertainment of improved visual acuity after cataract extraction. A secondary endpoint analysis included eyes that needed cataract extraction at the final follow-up examination.

RESULTS

For the primary analyses (clear lens preoperatively), there were 26 patients in the study group, 38 in the macular hole control group, and 18 in the epiretinal membrane control group. The cumulative cataract extraction rates at 2 years were 15%, 66%, and 53% respectively. By using multivariate survival analysis, the patient age was an important factor, with a younger age associated with a lower rate of progression to nuclear sclerosis. After controlling for age, the difference in these three groups was still statistically significant. In the four patients with diabetes undergoing cataract surgery, the visual acuity improved at least two lines in only one of the eyes and did not change in three eyes. After expanding the outcome measures to include study patients with mild lens opacities at baseline or those judged to be in need of cataract surgery at the final follow-up examination, there was still a strongly statistically significant difference between the three groups.

CONCLUSION

The rate of cataract extraction after vitrectomy in patients with diabetes is lower than in patients without diabetes undergoing vitrectomy and suggests a lower rate of cataract formation. This inference should be considered when attributing subnormal vision in a patient who has had a diabetic vitrectomy to a cataract. This is especially significant because the risk ratio in patients with diabetes in general and in patients with a previous vitrectomy is likely less favorable compared with the general population.

Deposition of silicone oil droplets in the residual anterior lens capsule after vitrectomy and lensectomy in rabbits

AIM

To examine the histology of preserved anterior lens capsule in vitrectomised and lensectomised rabbit eyes with and without silicone oil tamponade.

METHODS

Forty adult Japanese albino rabbits received two port vitrectomy and lensectomy with or without silicone oil tamponade in one eye under both general and topical anaesthesia. Anterior lens capsule was preserved during operation. After healing intervals residual anterior capsule was histologically observed under light or electron microscopy.

RESULTS

Immediately after operation, cuboidal lens epithelial cells were observed on the posterior surface of the preserved anterior capsule. During healing intervals in eyes with or without silicone oil tamponade, regenerated lens structure of Sommerring's ring and fibrous tissue formed in the peripheral and central areas of the residual capsule, respectively. Ultrastructural observation revealed the presence of many vacuoles amid matrix accumulation on the posterior capsular surface, suggesting the deposition of emulsified silicone oil droplets.

CONCLUSION

Lens epithelial cells produce regenerated lenticular structure and fibrous tissue on the residual capsule following vitrectomy and lensectomy in rabbits. Silicone oil droplets formed by its emulsification deposit in extracellular matrix accumulated on the posterior surface of the anterior capsule. Emulsified silicone may potentially enhance opacification of residual anterior capsule following pars plana vitrectomy by silicone oil deposition and subsequent activation of lens epithelial cells.

Combined surgery and sequential surgery comprising phacoemulsification, pars plana vitrectomy, and intraocular lens implantation: comparison of clinical outcomes

PURPOSE

To evaluate the effectiveness and safety of combined phacoemulsification, pars plana vitrectomy (PPV), and intraocular lens (IOL) implantation in diabetic and nondiabetic patients and compare the clinical results with those of sequential surgery.

SETTING

Seoul National University College of Medicine, Seoul, South Korea.

METHODS

The results of combined phacoemulsification, PPV, and IOL implantation in 52 patients (52 eyes) were retrospectively analyzed. The main outcome measures were preoperative and postoperative best corrected visual acuity (BCVA), postoperative BCVA of 20/40 or better, and intraoperative and postoperative complications. Combined surgery and sequential surgery were also compared using the same outcome measures.

RESULTS

Postoperatively, the BCVA was better in 44 eyes (84.6%); 12 eyes (23.1%) achieved a BCVA of 20/40 or better. Postoperative complications consisted of a transient intraocular pressure increase in 29 eyes (55.8%), hyphema in 10 (19.2%), neovascular glaucoma in 8 (15.4%), anterior chamber fibrin exudation in 7 (13.5%), vitreous hemorrhage in 7 (13.5%), retinal detachment in 3 (5.8%), and posterior capsule opacification in 1 (1.9%). In the diabetic patients, postoperative visual outcomes between the combined-surgery group and the sequential-surgery group were not significantly different; however, neovascular glaucoma occurred only in the combined-surgery group. Other complications were not different between the combined-surgery group and the sequential-surgery group. In the nondiabetic patients, the postoperative visual outcomes and complications between the 2 groups were not significantly different.

CONCLUSIONS

Combined phacoemulsification, PPV, and IOL implantation was safe and effective in selected patients, with the clinical outcomes comparable to those of sequential surgery.

Combined phacoemulsification, vitrectomy, foreign-body extraction, and intraocular lens implantation

PURPOSE

To assess the outcome of simultaneous phacoemulsification, pars plana vitrectomy, intraocular foreign-body extraction, and intraocular lens (IOL) implantation.

SETTING

SSK Ankara Eye Hospital, Department of Vitreoretinal Surgery, Ankara, Turkey.

METHODS

Seventeen patients with corneal perforation, intraocular foreign body, vitreous hemorrhage, and lens opacity had simultaneous clear corneal phacoemulsification, pars plana vitrectomy, intraocular foreign-body extraction, and IOL implantation.

RESULTS

Postoperative complications included massive retinal fibrosis in 2 patients, retinal detachment in 1, and cilioretinal artery occlusion in 1. At a mean follow-up of 15.2 months, best corrected visual acuity improved in the remaining 13 eyes (76%). The IOL was stable in all cases.

CONCLUSION

Combined phacoemulsification with IOL implantation and vitreoretinal surgery was safe in selected cases of penetrating ocular trauma resulting from an intraocular foreign body.

Vitrectomy in the management of diabetic retinopathy

According to the Early Treatment Diabetic Retinopathy Study, at least 5% of eyes receiving optimal medical treatment will still have progressive retinopathy that requires laser treatment and pars plana vitrectomy. During the past decade, improvements in instrumentation and surgical techniques have allowed more difficult cases of diabetic retinopathy to be candidates for vitrectomy. However, although the thresholds for performing surgery within established indicated situations have been lowered, only a few additional indications have been established. Although vitrectomy improves the prognosis for a favorable visual outcome, preventive measures, such as improved control of glucose levels and timely application of panretinal photocoagulation, produce better results. The authors review the indications, techniques, and results of vitrectomy in the management of diabetic retinopathy.

Combined phacoemulsification, pars plana vitrectomy, removal of intraocular foreign body (IOFB), and primary intraocular lens implantation for patients with IOFB and traumatic cataract

PURPOSE AND METHODS

Small-incision cataract extraction by phacoemulsification through an anterior continuous circular capsulorhexis, pars plana vitrectomy, forceps removal of intraocular foreign body (IOFB) and primary intraocular lens implantation were performed in 4 eyes (4 patients) with IOFB and traumatic cataract, as an emergency combined procedure.

RESULTS

At a mean follow-up of 12.3 months (range 7-19 months) the best corrected visual acuity of the 4 eyes ranged from 6/6 to 6/12. The only complication encountered in our series was an opacified posterior capsule that developed 10 months post-operatively in one case. This was easily dealt with by neodymium:YAG laser capsulotomy, with good final visual outcome.

CONCLUSIONS

The results of combined one-stage instead of sequential surgeries, and phacoemulsification instead of lensectomy or extracapsular cataract extraction for patients with IOFB and cataract are encouraging. It could be a good option in selected cases. However, the safety and efficacy of this combined procedure need to be evaluated further by a larger-scale, longer follow-up study.

Simultaneous posterior chamber intraocular lens implant combined with vitreoretinal surgery for intraocular foreign body injuries

To evaluate the safety of simultaneous posterior chamber intraocular lens (IOL) implant combined with complex vitreoretinal surgery for ocular trauma due to intraocular foreign body (IOFB).

METHODS

We undertook a retrospective analysis of 10 patients who had undergone simultaneous cataract extraction, vitreoretinal surgery, removal of IOFB and posterior chamber IOL implant, for ocular trauma due to IOFB. The visual outcome and complications were noted. The surgical procedure is described.

RESULTS

Ten young, male patients were followed for 5-30 months post-operatively. The post-operative visual acuity in the operated eye remained the same or improved as compared with their pre-operative vision. Eight patients had a visual acuity of 6/9 or better. One patient developed post-operative infective endophthalmitis. Three patients had retinal detachment post-operatively. The IOL was stable in all patients.

CONCLUSIONS

Simultaneous posterior chamber IOL implant with vitreoretinal surgery is safe in selected cases of severe ocular trauma due to IOFB. It allows early visual rehabilitation of young, working patients.

Change in postoperative refractive error when vitrectomy is added to intraocular lens implantation

PURPOSE

To compare the actual and expected refractive errors after intraocular lens (IOL) implantation alone with those after IOL implantation with simultaneous vitrectomy.

SETTING

Shinjo Eye Clinic, Miyazaki, Japan.

METHOD

One hundred thirty-six eyes had cataract extraction and implantation of a single-piece IOL using a frown incision, continuous annular anterior capsule tear, phacoemulsification, and intracapsular lens fixation. Thirty-six eyes also had vitrectomy.

RESULTS

Mean postoperative refractive error was 0.55 diopter (D) +/- 1.34 (SD) in eyes having no vitrectomy and 0.04 +/- 1.24 D in those having vitrectomy. The difference between groups was statistically significant (P = .047; t-test).

CONCLUSION

The refraction after simultaneous IOL implantation and vitrectomy shifted toward myopia by a mean of 0.50 D compared with that after IOL implantation alone.

Primary intraocular lens implantation in the setting of penetrating ocular trauma

PURPOSE

To evaluate the clinical outcome of patients who underwent lensectomy and intraocular lens (IOL) implantation at the time of primary repair of a penetrating ocular injury.

METHODS

A review of 14 patients who sustained cataracts and lens rupture in the setting of a corneal laceration to determine anatomic and visual outcome, in addition to complications related to the primary IOL.

RESULTS

The IOL remained anatomically stable in all 14 patients with no complications encountered at implantation or after surgery. Final visual acuity in 9 of the 14 patients was 20/40 or better. Six patients underwent pars plana vitrectomy for removal of an intraocular foreign body.

CONCLUSION

Intraocular lens implantation at the time of lensectomy and primary repair of a corneal laceration allows good visual rehabilitation with restoration of binocular function and serves as an alternative to contact lens correction in select patients.

Vitrectomy in the management of diabetic eye disease

Vitrectomy techniques including endolaser photocoagulation allow visual rehabilitation in many eyes that are otherwise untreatable. Discerning the indications and timing for diabetic vitrectomy is increasingly important as the treatment of complications of diabetic retinopathy continues to undergo modification and redefinition. The most common indications for diabetic vitrectomy include: 1) severe nonclearing vitreous hemorrhage; 2) traction retinal detachment recently involving the macula; 3) combined traction and rhegmatogenous detachment; 4) progressive fibrovascular proliferation; and 5) rubeosis iridis and vitreous hemorrhage for eyes in which the media opacity has prevented adequate laser photocoagulation. Other less common indications in selected cases include dense premacular hemorrhage, ghost cell glaucoma, macular edema with premacular traction, cataract preventing treatment of severe, proliferative diabetic retinopathy, anterior hyaloidal fibrovascular proliferation, and fibrinoid syndrome with retinal detachment. The rationale and surgical objectives are discussed and results are summarized.