Differences between the combination of the 25-gauge vitrectomy with phacoemulsification versus 20-gauge vitrectomy and phacofragmentation

Cost-effectiveness of the triple procedure - phacovitrectomy with posterior capsulotomy compared to phacovitrectomy and sequential procedures

PURPOSE

To evaluate the cost-effectiveness of the triple procedure (phacovitrectomy + posterior capsulotomy, PhacoPPVc) compared to the double- (phacovitrectomy, PhacoPPV) or single sequential procedures.

METHODS

Prospective study on 31 eyes from 31 patients (mean age: 72.1 ± 9.1 years; 55% females) was performed with a preoperative decision to undergo only pars plana vitrectomy (PPV) (26%) or PhacoPPV (74%) and/or posterior capsulotomy based upon presence or absence of lens opacification or pseudophakia. Time during and between surgeries, surgical procedure codes, medical and transport costs, outcome and likelihood of complications after surgery were all included in the analysis. Societal perspectives and visual acuity were considered as measures of quality of adjusted life years (QALYs).

RESULTS

About 23 eyes underwent triple procedure and eight eyes underwent vitrectomy only (mean surgery times: 35.9 and 24.0 min, respectively). Posterior capsulotomy took on average 30 s, while preparation and cataract procedure took 13.0 min. The patients travelled on average 80km (average cost: $280.12) to the surgery unit. The average reimbursement fee for the day procedures ranged between $174.17 (YAG capsulotomy; Diagnosis Related Group (DRG): 0.034), $1045.48 (Phaco + intraocular lens (IOL); DRG: 0.204) and $1701.32 (PPV; DRG: 0.332). The combined procedures excluded lens and laser reimbursements, while the calculated reimbursements for the double/triple procedures were $2713.08/$2901.45, respectively, without significant loss of QALYs. PhacoPPVc was found to be unequivocally cost-effective, while PhacoPPV remained cost saving compared to sequential procedures.

CONCLUSION

This study confirms that the triple procedure has benefits to the patients, health institution and surgeon. For patients, it saves them travel and healing time; for health institution, it justifies the calculated higher costs and need for higher reimbursement for the double/triple procedures, which are cost saving.

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.

Safety of 20-gauge transconjunctival sutureless vitrectomy

PURPOSE

To study the safety of 20-gauge transconjunctival sutureless vitrectomy.

METHODS

Clinical data of patients who underwent 20-gauge transconjunctival sutureless vitrectomy for the first time, for various disorders, were reviewed retrospectively. The main outcome measures were the number of sclerotomies requiring suturing as well as the intra- and postoperative complications.

RESULTS

A total of 179 operations were performed. Indications for vitrectomy included 68 idiopathic epiretinal membranes, 26 macular holes, 23 phakic and 16 pseudophakic retinal detachments, and 46 various other, less common etiologies. Of these 179 operations, 166 (93%) were sutureless. Of the 537 sclerotomies created, 25 (5%) received a single transconjunctival-scleral suture. Intraoperative complications included premature dislodging of the cannulas in 2 sclerotomies and an iatrogenic horseshoe tear at 1 sclerotomy site. Postoperative complications comprised transient hypotony in 14 cases, subconjunctival gas in 2 cases, and choroidal effusion in 1 case. No serious complications (such as endophthalmitis) were observed.

CONCLUSION

20-gauge transconjunctival sutureless vitrectomy can be considered safe, as the intra- and postoperative complications observed are neither numerous nor significant. Sclerotomies appear to be safe and relatively easy to perform, without compromising the advantages of sutureless surgery.

Advantages and limitations of small gauge vitrectomy

Small gauge vitrectomy utilizing 23- and 25-gauge instrumentation has definite advantages, but also limitations, due to the physics of smaller instruments and sutureless surgery. Higher infusion and aspiration pressures are needed to remove the vitreous using 23- and 25-gauge probes. The advantages include decreased surgical times, less tissue manipulation, reduced inflammation and pain postoperatively with more rapid visual recovery. A disadvantage is greater instrument flexion than 20-gauge probes, making small gauge vitrectomy more appropriate for indications such as vitreous opacities, epiretinal membranes, macular holes, and simple retinal detachments. There are also some increased complications related to small gauge vitrectomy, including dislocation of cannulas intraoperatively, early postoperative hypotony, choroidal detachment, and possibly an increased risk of infectious endophthalmitis.