Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification in patients with proliferative diabetic retinopathy

Intraoperative challenges and complications of cataract surgery between cataract surgery alone and phacovitrectomy in eyes with diabetic retinopathy: efficacy of illuminated chopper-assisted cataract surgery

BACKGROUND

To compare the intraoperative challenges, complications, and operation time of illuminated chopper-assisted cataract surgery between cataract surgery only and phacovitrectomy in eyes with diabetic retinopathy.

METHODS

One university hospital, retrospective case series. Two hundred ninety-five eyes of 295 consecutive patients with diabetic retinopathy who underwent cataract surgery only or phacovitrectomy were retrospectively reviewed. Intraoperative challenges and complications of cataract surgery were thoroughly analyzed by 3D viewing of digitally recorded videos. The pupil diameter, operation time, and improved efficacy (100/operation time × pupil diameter) were compared between the cataract surgery only and phacovitrectomy groups.

RESULTS

Of the 295 eyes, 211 underwent cataract surgery only, and 84 underwent phacovitrectomy. Intraoperative challenges such as small pupil, miosis, or poor red reflex occurred more frequently (46 [21.8%] vs. 28 [33.3%], p = 0.029); pupil diameter was smaller (7.34 ± 0.94 vs. 6.89 ± 0.88 mm, p < 0.001) in the phacovitrectomy group than in the cataract surgery only group; however, rates of posterior capsule rupture and operation time were not different between the two groups (0 [0%] vs. 1 [1.2%], p = 0.285; 16.54 ± 2.65 vs. 16.31 ± 4.30 min, p = 0.434). Improved efficacy was higher in the phacovitrectomy group (0.85 ± 0.18 vs. 0.97 ± 0.28, p = 0.002).

CONCLUSIONS

The use of an illuminated chopper is a potential solution for diabetic cataract surgery, particularly in phacovitrectomy, by decreasing the use of supplemental devices, operation time, and posterior capsule rupture.

TRIAL REGISTRATION

Retrospectively registered.

Postoperative complications of combined phacoemulsification and pars plana vitrectomy in diabetic retinopathy patients

Purpose

To compare intra- and postoperative complications in combined phacoemulsification and pars plana vitrectomy surgeries performed in patients with non-proliferative diabetic retinopathy (NPDR) vs. proliferative diabetic retinopathy (PDR).

Methods

Retrospective, case series of patients with diabetic retinopathy who underwent combined phacovitrectomy surgery between 2008 and 2017. We compared intraoperative complications including posterior capsular rupture and retinal tear, and postoperative complications including corneal edema, macular edema (ME), epiretinal membrane (ERM), neovascular glaucoma and persistent inflammation.

Results

A total of 104 eyes of 104 patients were included in this study. Twenty-four eyes (23.1%) were categorized as NPDR and 80 eyes (76.9%) as PDR. The most common indications for surgery in the NPDR group were ERM (67%) and rhegmatogenous retinal detachment (12.5%), while in the PDR group, indications were vitreous hemorrhage (56%) and tractional retinal detachment (19%). The most common intraoperative complication was retinal tear (8% in NPDR and 19% in PDR, p = 0.195) and postoperative complication was ME (29% in NPDR and 26% in PDR, p = 0.778). There were no statistically significant differences in intra- and postoperative complication rates between the NPDR and PDR groups, even after adjusting for confounders; patient age at surgery and indication for surgery.

Conclusion

After combined phacovitrectomy in NPDR and PDR patients, new-onset ME was found in about a quarter of eyes in both groups. Intraoperative anti-VEGF or steroid administration, and intense postoperative anti-inflammatory medication and follow-up should be regarded after phacovitrectomy regardless of the DR level.

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.

The incidence and risk factors of neovascular glaucoma secondary to proliferative diabetic retinopathy after vitrectomy

OBJECTIVE

The incidence and risk factors of neovascular glaucoma (NVG) secondary proliferative diabetic retinopathy (PDR) after pars plana vitrectomy (PPV) are unclear and reports in the published literature are inconsistent. Therefore, a systematic review and meta-analysis were conducted to clarify the risk factors associated with neovascular glaucoma.

METHODS

PubMed, Embase, and The Cochrane Library were systematically searched without language limitations for studies related to NVG after PPV in PDR patients. We used R software to fit the correlation between incidence and the date of publication for studies and performed a Spearman analysis. For binary and continuous variables, the odds ratios (ORs) with 95% confidence intervals (CIs) were pooled, respectively, using Review Manager 5.3 (The Cochrane Collaboration).

RESULTS

Twenty-six studies with 5161 patients were included in our meta-analysis. The overall pooled incidence of NVG after PPV in PDR patients was 6% (95% CI, 0.05-0.07, p-value < 0.00001). Pooled estimates indicated a positive correlation for NVG after PPV in PDR patients with higher baseline IOP (OR, 1.26; 95%CI,0.56-1.95, p-value = 0.0004), preoperative iris neovascularization (INV) (OR, 5.66; 95% CI, 2.10-15.23, p-value = 0.0006), preoperative or intraoperative combined cataract surgery (OR, 2.00; 95% CI, 1.15-3.46, p-value = 0.01), postoperative vitreous hemorrhage (VH) (OR, 3.53; 95% CI, 1.63-7.66, p-value = 0.001), and a negative correlation with age (OR, -2.90; 95%CI, -5.00 to -0.81, p-value < 0.007).

CONCLUSION

Our systematic review and meta-analysis indicated that the main risk factors for NVG after PPV in PDR patients included higher baseline IOP, preoperative INV, preoperative or intraoperative combined cataract surgery, postoperative VH, and was negatively correlated with age.

Predictive Risk Factors for Retinal Redetachment Following Uncomplicated Pars Plana Vitrectomy for Primary Rhegmatogenous Retinal Detachment

Purpose: To investigate clinical and surgical factors influencing the outcome after primary rhegmatogenous retinal detachment surgery. Methods: A retrospective, single-centre, case-control study of 1017 eyes of 1017 consecutive patients with primary rhegmatogenous retinal detachment (RRD) who underwent pars plana vitrectomy (PPV), were included in the study. Analysed surgical factors were: combined procedure with phacoemulsification, type of retinopexy (cryocoagulation, endolaser, combined), type of tamponade (gas, silicone oil), and anatomical factors: primary proliferative vitreoretinopathy (PVR) and macular detachment at the time of surgery. Results: Overall retinal re-detachment rate was 10.1%. The main reason for re-detachment was an insufficient retinopexy in 53.6%, followed by PVR (37.3%), and retinal detachment occurred at a different location caused by another break in 9.1%. No significant difference in the rate of re-detachment was found if a phacoemulsification with simultaneous IOL implantation was performed (p = 0.641). No significant difference between the various retinopexy techniques was found (p = 0.309). Risk factors re-detachment were primary PVR (p = 0.0003), silicone oil as initial tamponade (p = 0.0001) as well as macula off detachments (p = 0.034). Conclusions: The present study showed no significant difference between the types of retinopexy and if additional phacoemulsification was performed or not. Factors associated with a higher risk for re-detachment were detached macula at surgery, primary PVR and primary oil-filling.

Combined pars plana vitrectomy with phacoemulsification for rhegmatogenous retinal detachment repair

Purpose

To investigate the outcome after combined phaco-vitrectomy in rhegmatogenous retinal detachment (RRD) repair.

Patients and methods

In this retrospective study, we included all patients who underwent pars plana vitrectomy (PPV) for RRD between January 2013 and December 2017. The main outcome measure was the retinal re-detachment rate after combined phaco-vitrectomy.

Results

Overall, 1017 eyes with RRD were included. All eyes received PPV, while in 516 eyes additional phacoemulsification was performed. A retinal re-detachment occurred in 103 patients (10.1%). No significant difference in the rate of re-detachment was found if additional phacoemulsification was performed (p=0.641). Subgroup calculations showed a significant higher rate of re-detachment in patients with a PVR (p=0.0003) and in patients where silicone oil was used as primary tamponade (p=0.0001) as well as in macula off RRDs (p=0.034).

Conclusion

Additional phacoemulsification during vitrectomy for RRD is not associated with higher rate of retinal re-detachment.

VISUAL AND ANATOMICAL OUTCOMES AFTER DIABETIC TRACTION AND TRACTION-RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To evaluate visual and anatomical outcomes of diabetic tractional retinal detachment repaired with pars plana vitrectomy.

METHODS

Operative records were used to retrospectively identify all patients with tractional retinal detachments secondary to proliferative diabetic retinopathy surgically repaired with pars plana vitrectomy between November 1, 2009, and January 1, 2015 at the LAC + USC (Los Angeles County + University of Southern California) Medical Center.

RESULTS

A total of 403 eyes with diabetic tractional retinal detachment in 359 patients were included. Successful reattachment of the retina was achieved in 87.6% of eyes after one surgery and 92.6% of eyes at the final follow-up. Best-corrected visual acuity at the final follow-up improved two or more lines in 56.3% of eyes, was stable in 23.8% of eyes, and decreased two or more lines in 19.9% of eyes. Eyes repaired with 23-gauge and 25-gauge vitrectomy systems had similar success rates as eyes treated with 20-gauge instrumentation (P = 0.73). Eyes receiving silicone oil tamponade had lower single-surgery reattachment rates (77.6% vs. 87.6%; P = 0.013), lower reattachment rates at the final follow-up (85.7% vs. 92.6%; P = 0.048), and higher rates of vision loss (34.7% vs. 19.9%; P < 0.0001) but were more likely to have concurrent rhegmatogenous detachment (47.0% vs. 21.3%; P < 0.0001) and macula involving detachment (74.5% vs. 60.0%; P < 0.0001).

CONCLUSION

In this large, single-center retrospective study of patients with advanced diabetic tractional retinal detachment, vitrectomy achieved excellent anatomical outcome and improved or stabilized vision in 80.1% of eyes. Smaller gauge vitrectomy systems were found to have similar outcomes to 20-gauge instrumentation.

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

Outcome and Complications of Combined Phacoemulsification and 23-Gauge Pars Plana Vitrectomy

Background

With the advances in surgical tools, simultaneous removal of cataract associated with vitreoretinal disorders is gaining popularity. This combined surgery offers several advantages besides limitations. The aim of this study is to assess the outcome and complications of phacoemulsification combined with pars plana vitrectomy (PPV).

Patients and Methods

In this retrospective review, medical charts of patients undergoing phacovitrectomy for coexisting cataract and various vitreoretinal disorders were analyzed. Patient demographics, retinal diagnosis, visual acuities (VA) in logMAR, intraocular pressure (IOP), intraoperative and postoperative complications were assessed. Clear corneal phacoemulsification and 23-gauge transconjunctival PPV were administered in all cases.

Results

Eighty-four eyes of 64 (76.2%) males and 20 (23.8%) females were enrolled. The average age of patients was 59.5 ± 13.8 (18–81). The average period of follow-up was 7.2 ± 7.5 months (1–36). The vitreoretinal diagnoses were as follows: 28 (33.3%) rhegmatogenous retinal detachment, 23 (27.4%) vitreous hemorrhage, 12 (14.3%) intraocular foreign body, 12 (14.3%) epiretinal membrane, 4 (4.8%) macular hole, 4 (4.8%) tractional retinal detachment, and 1 (1.2%) vitreomacular traction. The most common intraoperative complications were miosis and rupture of the posterior capsule (92.9% and 8.3%, respectively). In 8 (9.5%) cases, there was fibrin in the anterior chamber. Posterior synechia developed in 7 (8.3%) of cases. No severe increase in intraocular pressure was evident.

Conclusion

Phacoemulsification combined with PPV is a safe and efficient way of management in cases where cataract coexists with vitreoretinal pathologies.

Cataract surgery in diabetes mellitus: A systematic review

India is considered the diabetes capital of the world, and a significant proportion of patients undergoing cataract surgery are diabetic. Considering this, we reviewed the principles and guidelines of managing cataract in patients with diabetes. The preoperative, intraoperative, and postoperative factors are of paramount importance in the management of diabetic cataract patients. Particularly, the early recognition and treatment of diabetic retinopathy or maculopathy before cataract surgery influence the final visual outcome and play a major role in perioperative decision-making. Better understanding of various factors responsible for favorable outcome of cataract surgery in diabetic patients may guide us in better overalll management of these patients and optimizing the results.

Clinical outcome of 23g Trans-Conjunctival pars plana vitrectomy - a prospective comparison of Phaco-Vitrectomy with only vitrectomy in phakic eyes

Objective

To evaluate the effectiveness and safety profile of combined phacoemulsification with 23G pars plana vitrectomy when compared to pars plana vitrectomy alone in phakic patients.

Methods

This study was performed at Al-Ehsan Eye Hospital (tertiary care eye hospital in Lahore, Pakistan) from January 2016 to August 2016. A total of 40 eyes in two equal groups of 20 eyes each, were enrolled in this prospective study. Group-A underwent combined phaco-vitrectomy, whereas Group-B underwent vitrectomy only for various vitreoretinal pathologies. We evaluated the safety of combined surgery, intra-operative and postoperative complications and short term surgical outcome.

Results

The most common reason for vitreoretinal intervention was rhegmatogenous retinal detachment followed by vitreous haemorrhage in combined study population. There was statistically significant difference in best corrected visual acuity pre-operatively and post operatively within the groups and between the groups. The most significant immediate post operative observation in Group-A was enhanced anterior chamber inflammation as compared to Group-B, whereas most signification observation in Group-B was development of visually significant cataract (35%) at 6 months follow-up. There was no other significant sequel or complication difference between both groups.

Conclusions

Combined phaco-vitrectomy is a safe and effective procedure with minimum complication profile and it avoids the need of subsequent cataract surgery.

COMPLEX RETINAL DETACHMENT IN PHAKIC PATIENTS: Previtrectomy Phacoemulsification Versus Combined Phacovitrectomy

Previtrectomy cataract surgery was associated with less extensive postoperative posterior synechia, however, its final functional and anatomical outcomes were not significantly different from those of combined phacovitrectomy. Both approaches were efficacious.

Purpose:

To assess the impact of phacoemulsification performed one week before pars plana vitrectomy versus combined phacovitrectomy on postoperative anterior segment status and final functional and anatomical outcomes in phakic patients affected by complex rhegmatogenous retinal detachment.

Methods:

The authors retrospectively reviewed the records of 59 phakic patients affected by complex rhegmatogenous retinal detachment. Twenty-nine patients underwent cataract surgery 7 days before vitrectomy (preemptive cataract surgery—Group 1), whereas 30 patients underwent combined phacovitrectomy (Group 2). Preoperative, intraoperative, early- and late-postoperative outcomes were measured and compared.

Results:

Numbers of previous retinal surgical procedures, nuclear sclerosis grade, proliferative vitreoretinopathy grade, eyes with inferior breaks, surgical time, and ratio of silicone oil/gas tamponade were all similar between the two groups. After surgery, there was less extension of posterior synechia in Group 1. There was no significant difference in fibrin, number of patients with posterior synechia, final intraocular pressure, retinal redetachment rate, final retinal status, or final best-corrected visual acuity.

Conclusion:

Preemptive cataract surgery was associated with less extensive postoperative posterior synechia, however, its final functional and anatomical outcomes were not significantly different from those of phacovitrectomy. Both approaches were efficacious.

Chandelier retroillumination-assisted cataract surgery during vitrectomy

PurposeTo present an alternative cataract surgical technique in patients with cataract and intravitreal hemorrhage.MethodsTwelve cases with poor fundus reflex caused by severe vitreus hemorrhage were included in the study. All patients underwent combined phaco surgery and 23-gauge vitrectomy. Chandelier retroillumination was inserted into the infusion trochar during the cataract operations and was used with low power (50-75%) in necessary steps.ResultsWe did not experience phaco complications or complications due to technique during surgery. Retroillumination assistance was especially useful during final stages of cataract surgery, particularly irrigation-aspiration of cortical material.ConclusionRetroillumination in absence of red fundus reflex may be helpful and can be practiced more often in cataract surgery combined with vitrectomy.

Secondary Angle-Closure Glaucoma Due to Posterior Synechiae of Iris Following Combined Phacoemulsification and 23-Gauge Transconjunctival Vitrectomy

PURPOSE

To describe the clinical characteristics of eyes with secondary angle-closure glaucoma following combined phacovitrectomy.

METHODS

Retrospective case series.

RESULTS

Nine eyes developed angle-closure glaucoma due to iris posterior synechiae with an incidence rate of 1.82% (95% CI: 0.64 - 3%) among 493 eyes following phacovitrectomy. PDR with TRD was the most common surgical indication. Single piece IOL insertion and silicone oil were present in all cases. Fibrin in the anterior chamber was found in six eyes postoperatively. Mean degree of iris bombe was 310±79.37° at 3.55±1.87 weeks with a mean IOP of 32.56±5.89 mm of Hg. Systemic diabetes and grade of cataract were the only significant risk factors (r² =1; p= 0.016 and 0.049, respectively). Nd:YAG laser PI relieved the angle-closure attack in all cases.

CONCLUSION

Systemic diabetes and advanced grade of cataract are significant risk factors for secondary angle-closure glaucoma following combined phacovitrectomy.

Surgical and Functional Results of Hybrid 25-27-Gauge Vitrectomy Combined with Coaxial 2.2 mm Small Incision Cataract Surgery

Purpose. To investigate outcomes after coaxial 2.2 mm small incision cataract surgery combined with hybrid 25-27-gauge vitrectomy in eyes with vitreoretinal disease and age-related cataract. Methods. A single-center, retrospective case series study of 55 subjects (55 eyes) with a mean age of 70 years who underwent combined small incision phacoemulsification, intraocular lens (IOL) implantation, and hybrid 25-27-gauge vitrectomy during the 12-month period to December 2014. Intraoperative and postoperative complications and visual results were the main outcome measures. Results. The mean follow-up period was 6 months (range: 2–18 months). Intraoperative findings were 3 retinal breaks (5.5%). No cases required corneal or scleral suture or conversion to larger-gauge vitrectomy. Postoperative complications consisted of posterior capsule opacification (12.7%), elevated intraocular pressure >30 mmHg (1.8%), and fibrin reaction (5.5%). There were no cases of hypotony (<7 mmHg), IOL decentration, or postoperative endophthalmitis. Visual acuity (mean ± SD) improved from 0.52 ± 0.6 logMAR preoperatively to 0.22 ± 0.46 logMAR at final postoperative visit (P < 0.0001). Conclusion. Surgical and visual outcomes suggest hybrid 25-27-gauge vitrectomy combined with small incision phacoemulsification and IOL implantation is feasible, safe, and effective as a one-step surgical procedure for the management of vitreoretinal pathologies and concurrent cataract.

Novel approach for phacoemulsification during combined phacovitrectomy

Purpose

To evaluate the safety and efficacy of surgeon’s superior sitting position during temporal clear corneal incision (TCCI) phacoemulsification, with a 90° working angle, during combined phacovitrectomy.

Methods

Prospective interventional case series were performed on 65 eyes of 63 patients. TCCI phacoemulsification was done in all cases (whether right or left eyes), while the surgeon was sitting superiorly to the operating table.

Outcome measures included

Shift in sitting position, keratometric astigmatism, surgically induced astigmatism, posterior capsule integrity, and intraocular lens centration.

Results

Phacoemulsification was performed completely in all cases (100%). Shift in position to temporal sitting position happened in two cases (3%). The keratometric astigmatism showed mean changes of 1.09 D (0.25–3.75 D) to 0.84 D (0.00–3.25 D) at 1 month, which remained stable at 6 months; 0.84 D (0.16–3.21 D). The surgically induced astigmatism was 0.25 DC (−0.50 to 1.0 DC) at 1 month, which stayed stable at 6 months; 0.25 D (−0.63 D to 0.98 D). Posterior capsular rupture occurred in one case (the second case) (1.5%). The intraocular lens was centered in all cases (100%).

Conclusion

Superior sitting TCCI phacoemulsification, with a wide working angle, during combined phacovitrectomy proved safe and easy, without the burden of changing and disrupting the operative setting. The anatomical and optical outcomes were acceptable.

Trimanual technique using assistant-controlled light probe illumination and wide-angle viewing system in 23-gauge sutureless vitrectomy for diabetic tractional retinal detachment

BACKGROUND AND OBJECTIVE

The authors propose a novel trimanual vitreous surgery using assistant-adjusted endoillumination during 23-gauge sutureless vitrectomy for severe diabetic tractional retinal detachment (TRD) under noncontact wide-angle viewing system.

MATERIALS AND METHODS

The trimanual sutureless vitrectomy under a wide-angle viewing system consisted of (1) a fourth-port microcannula in the inferior 6-o'clock position; (2) dynamic and specular illumination by an assistant-controlled light probe inserted through the fourth port; and (3) membrane dissection and bleeding control using two intraocular instruments.

RESULTS

Six eyes of four patients who underwent trimanual diabetic vitrectomy were evaluated. Recurrent TRD was detected in one eye, and a second operation was performed. There were no intraoperative sclerotomy-related complications or postoperative hypotony, increased IOP, or endophthalmitis. Final anatomic and functional success was achieved in all six eyes.

CONCLUSION

The trimanual technique is valuable for membrane dissection in severe diabetic TRD. The optimal and dynamic illumination provided a high-quality stereoscopic view under a wide-angle viewing system. Careful coordination between a surgeon and an assistant facilitates this technique.

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification for rhegmatogenous retinal detachment repair

AIM

To assess the outcomes of combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification with intraocular lens implantation for rhegmatogenous retinal detachment (RRD) repair.

METHODS

This was a retrospective, consecutive, non-comparative, interventional case series of 30 eyes of 30 patients who underwent combined sutureless vitrectomy and clear corneal cataract surgery for the repair of RRD. The principal outcome measures were primary anatomical success rate, reasons for redetachment, final visual acuity, and surgical complications.

RESULTS

Primary reattachment was achieved in 27 eyes (90.0%). The reasons for redetachment (3 eyes, 10%) were incomplete laser retinopexy, persistent chronic subretinal fluid, and proliferative vitreoretinopathy, respectively. The logarithm of the minimum angle of resolution visual acuity (mean±SD) improved from 0.76±0.74 preoperatively to 0.21±0.37 6 months' postoperatively (P<0.0001). Postoperative hypotony was not detected, but 1 eye (3.3%) had increased intraocular pressure (30mmHg) with spontaneous resolution. No endophthalmitis developed during follow-up. Macular pucker was detected in 3 eyes (10.0%).

CONCLUSION

Combined 23-gauge sutureless vitrectomy and clear corneal phacoemulsification with intraocular lens implantation for RRD repair was proven safe and effective. It may provide not only the known advantages of conventional combined surgery, but also additional advantages such as less conjunctival fibrosis and the maintenance of stable intraocular pressure with low risks of postoperative hypotony and intraocular pressure elevation.

Cost of phacovitrectomy versus vitrectomy and sequential phacoemulsification

PURPOSE

To evaluate and compare the cost of combined pars plana vitrectomy and phacoemulsification/intraocular lens implantation (phacovitrectomy) to a sequential approach to the surgical procedures for patients with an indication for vitrectomy and a visually significant cataract.

METHODS

The total cost of both the combined and sequential approaches to surgery were calculated by combining the surgeon, ambulatory surgical center, and anesthesiology fees as reimbursed by Medicare. A univariate sensitivity analysis was also performed to examine the sensitivity of our estimations to changes in surgical duration.

RESULTS

Phacovitrectomy afforded a 17% to 20% per-patient cost savings to Medicare (depending on the type of vitrectomy) compared with vitrectomy with sequential phacoemulsification. The conclusion that phacovitrectomy was less expensive than sequential surgery was robust in sensitivity analysis.

CONCLUSION

Phacovitrectomy seems to be significantly less costly to Medicare than a sequential approach to surgery for patients with an indication for vitrectomy and a visually significant cataract.

Intracameral illuminator-assisted advanced cataract surgery combined with 23-gauge vitrectomy in eyes with poor red reflex

PURPOSE

To evaluate the efficacy and outcomes of intracameral illuminator-assisted advanced cataract surgery combined with 23-gauge vitrectomy in eyes with a poor red reflex.

SETTING

Department of Ophthalmology, Gachon University Gil Hospital, Incheon, Korea.

DESIGN

Interventional case series.

METHODS

Surgeon-controlled intracameral illumination was used for visualization during combined cataract surgery and 23-gauge vitrectomy. The main outcome measures were causes of the poor red reflex, value of the intracameral illuminator in specific cataract steps, and intraoperative and postoperative complications.

RESULTS

The study comprised 17 patients (17 eyes). The main causes of a poor red reflex were vitreous hemorrhage in 8 eyes, vitreous opacity in 6 eyes, and corneal opacity, bullous retinal detachment, and globe deviation in 1 eye each. Horizontal or oblique intracameral illumination minimized the amount of corneal scatter and reflection of the illuminating light and provided high-quality intraoperative lens images in most surgical steps. In addition, excellent visibility of the lens capsules facilitated the removal of almost all lens epithelial cells from the capsular bag. In all eyes, completion of the capsulorhexis and in-the-bag implantation of an intraocular lens were accomplished. In 1 eye, a radial anterior capsule tear occurred during irrigation/aspiration. Postoperatively, the rate of anterior capsule opacification was 11.8% (2/17 eyes) and of posterior capsule opacification, 23.5% (4/17 eyes).

CONCLUSIONS

Surgeon-controlled intracameral illumination provided excellent imaging and almost 360-degree visualization of the lens capsule structures. This capability can be used for challenging cataract surgery combined with vitrectomy in eyes with a poor red reflex.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

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.