A Modified Technique for Preventing Lens-Iris Diaphragm Retropulsion Syndrome in Vitrectomized Eyes during Phacoemulsification

BACKGROUND

Lens-iris diaphragm retropulsion syndrome (LIDRS) is common in vitrectomized or high myopic eyes during phacoemulsification. We evaluated the results of a modified technique for cataract treatment using phacoemulsification in vitrectomized eyes.

METHODS

In this retrospective study, we enrolled thirty-four vitrectomized eyes treated with modified phacoemulsification (Modified Group) and nineteen vitrectomized eyes treated with routine phacoemulsification (Control Group). The modified technique comprised irrigation with a balanced salt solution underneath the pupil before phacoemulsification instrument entry, lens implantation and stromal hydration to stabilize the anterior chamber and equilibrate the pressure between the anterior chamber and posterior cavity.

RESULTS

We compared the incidences of intra and postoperative complications and visual outcomes between modified and routine phacoemulsification. Pain, LIDRS and difficulty in stromal hydration were significantly more common in the Control Group than in the Modified Group (p < 0.05). There were no significant differences in the rates of posterior capsular rupture, iris trauma, lens dislocation, or posterior capsular opacification between the Modified and Control Groups (p > 0.05). However, there was no significant difference in visual acuity between the groups (p > 0.05). Complications such as loss of nuclear fragments into the vitreous cavity, cystoid macular edema, retina redetachment, suprachoroidal hemorrhage and vitreous hemorrhage did not occur either intra or postoperatively in any of our patients.

CONCLUSIONS

Our modified technique prevents LIDRS and complications arising during cataract surgery in vitrectomized eyes. Aside from this, the results of modified and routine phacoemulsification are similar in vitrectomized eyes.

OUTCOMES OF COMBINED PHACOEMULSIFICATION AND PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT: A Comparative Study

PURPOSE

To evaluate and to compare the anatomical and functional results of phacovitrectomy and pars plana vitrectomy (PPV) alone for phakic rhegmatogenous retinal detachment.

METHODS

Retrospective, comparative case series of 266 phakic eyes that underwent either combined phacovitrectomy or PPV alone for primary retinal detachment. The primary anatomical success rate, the final best-corrected visual acuity, and the refractive outcomes were analyzed.

RESULTS

One hundred and twenty-seven eyes were included in the combined group and 139 in the PPV group. The primary anatomical success rate was 84.3% in the combined group and 89.2% in the PPV group (P = 0.311). One hundred and nine (78.4%) eyes of the PPV group required cataract removal for visual rehabilitation during the follow-up period. There was no significant difference between the two groups in terms of the mean final best-corrected visual acuity (P = 0.185) and mean visual changes (P = 0.470). Overall, combined cataract extraction resulted in a significant myopic shift compared with delayed cataract surgery (P = 0.047).

CONCLUSION

Combined phacoemulsification and PPV is a safe and effective procedure to treat retinal detachment. The anatomical and functional results were comparable with those obtained with PPV and delayed cataract surgery. However, the refractive outcomes were less favorable and shifted toward myopia, especially in macula-off cases.

Visual outcomes following cataract surgery with intraocular lens implantation in vitrectomized eyes among children

Purpose:

To assess the visual outcomes and associated factors in pediatric patients undergoing cataract surgery following pars plana vitrectomy (PPV).

Methods:

A total of 52 eyes of 52 children who underwent cataract surgery and intraocular lens (IOL) implantation in previously vitrectomized eyes between January 2008 and December 2017 were included in this retrospective study. Descriptive and inferential statistical measurements (Chi-square test, Fisher's exact test, odds ratio, multiple logistic regression) were done.

Results:

The mean age at PPV was 11.3 ± 2.9 years. The most common indication for PPV was retinal detachment in 43 eyes (82.69%) and vitreous hemorrhage in 6 eyes (11.53%). The mean preoperative and postoperative best-corrected visual acuity (BCVA) was 1.31 ± 0.48 logMAR (logarithm of the minimum angle of resolution) units (20/400) and 0.69 ± 0.45 logMAR units (20/100), respectively; P < 0.001. The final visual outcome was good in 37 eyes (71.15%) and poor in 15 eyes (28.85%). In mean follow-up of 4 years, 42.3% developed posterior capsular opacification, 13.5% developed glaucoma, and 3.8% had retinal redetachment after cataract surgery. In the presence of macular pathology, the visual outcome was poor (aOR [adjusted odds ratio] = 4.26, P = 0.002).

Conclusion:

Cataract surgery with IOL implantation in vitrectomized eyes among children is a safe procedure and can improve visual acuity and quality of life. However, the extent of improvement is limited by macular pathology.

Cataract Following Pars Plana Vitrectomy: A Review

Introduction: The indications for pars plana vitrectomy (PPV) have increased over the years. The vitreous is no longer considered an inert ocular structure and it is well known that its removal has anatomical and physiological consequences. The vitreous is no longer considered an inert ocular structure. The vitreous plays a key role as an intraocular physiologic oxygen regulator. In order to maintain its transparency, the crystalline lens needs protection from an excessive oxygen exposure. PPV leads to progression of nuclear sclerosis in most eyes.Methods: A systematic review of the literature was conducted using Embase and Medline databases. Articles studying the physiology, pathogenesis and surgical treatment of cataract after PPV were included in this review.Results: The pathogenesis of cataract formation after PPV remains unclear. Predisposing factors include advanced patient age, preexisting nuclear sclerosis, light toxicity, intraoperative oxidation of lens proteins, use of silicone oil or intravitreal gas, mechanical trauma and the duration of exposure to an irrigating solution.Conclusion: Cataract surgery in vitrectomized eyes presents with more technical difficulties, is more challenging and often has a higher risk of intraoperative and postoperative complications than in non vitrectomized eyes. There is no standardized technique or management in these cases; therefore, it requires more precautions during surgery.

Accuracy of Intraocular Lens Power Calculation in Children With Vitrectomized Eyes Undergoing Cataract Surgery

PURPOSE

To assess the predictability of desired postoperative refractive outcomes using the SRK-II formula for intraocular lens (IOL) power calculation in children undergoing cataract surgery in eyes with a previous pars plana vitrectomy (PPV).

METHODS

In this retrospective study, 68 eyes of 66 children who underwent cataract surgery and IOL implantation in eyes that had previous vitrectomy between January 2008 and December 2017 were included. Data were collected on preoperative and postoperative characteristics. The Mann-Whitney test, Kruskal-Wallis test, and multinominal logistic regression were used for comparing the results.

RESULTS

Absolute prediction error (APE) in the cohort was 1.29 ± 1.13. Desirable refractive outcome with insignificant prediction error of less than 0.50 diopters (D) was found in approximately one-third of the children. Patients were further subdivided by magnitude of APE as ≥ 0.50 to ≤ 1.00 D and > 1.00 D. Age at the time of surgery, axial length, mean keratometry, silicone oil removal, IOL position, scleral buckle, and corneal suture did not affect APE and there was no significant difference between the groups (P > .05).

CONCLUSIONS

The mean APE of the SRK-II formula for IOL power calculation in pediatric eyes that had vitrectomy is comparable to that reported in the literature for routine pediatric cataract surgeries. Factors such as age, axial length, corneal power, IOL position (bag/sulcus), scleral buckle, corneal suture, and silicone oil removal done prior to surgery or along with cataract surgery did not affect the APE. [J Pediatr Ophthalmol Strabismus. 2021;58(2):126-131.].

[Distinctive features of phacoemulsification in previously vitrectomized eyes]

The review presents the main pathogenetic mechanisms of cataract development in an avitic eye as well as anatomical and functional changes of the eye in the state of avitria. The authors have also analyzed distinctive behavior of such eyes during phacoemulsification and surgical techniques used to answer specific avitreal phenomena.

Epiretinal membrane surgery: an analysis of 2-step sequential- or combined phacovitrectomy surgery on refraction and macular anatomy in a prospective trial

PURPOSE

To assess the impact of combined phacoemulsification-vitrectomy and sequential surgery for idiopathic epiretinal membrane (ERM) on refractive error (RE) and macular morphology.

METHODS

In this prospective clinical trial, we allocated phakic eyes with ERM to (1) cataract surgery and subsequent pars plana vitrectomy (PPV) (CAT group), (2) PPV and subsequent cataract surgery (VIT group) or (3) phaco-vitrectomy (COMBI group). Examinations were at baseline, one month after each surgery, and at 3 months and 12 months of follow-up. Primary outcome was the RE (the difference between predicted and achieved spherical equivalent); secondary outcomes were best-corrected visual acuity (BCVA), and incidence of cystoid macular oedema (CME) defined as >10% increment of central subfield macular thickness (CSMT).

RESULTS

Sixty-two eyes were enrolled. The mean RE showed a small myopic shift of -0.36D in all groups 1 month after surgery, decreasing after 12 months to -0.17D. The absolute value of the RE (ARE) ranged 0.49-0.68D after 12 months. In the immediate postoperative period, there was a higher incidence of CME in the CAT group. There was no significant difference in final RE, ARE, BCVA and CSMT between the groups. Four cases (17%) in the CAT group had resolved visual complaints and improved BCVA after cataract surgery resulting in no need for PPV within the follow-up period.

CONCLUSION

Surgery for idiopathic ERM in phakic eyes with either phaco-vitrectomy or sequential surgery are equal approaches with respect to functional- (RE, BCVA) and anatomical outcomes (CME, CSMT). However, if starting with cataract surgery, 17% of the cases may not need subsequent PPV.

PRIMARY CORE VITRECTOMY TECHNIQUE BEFORE CATARACT SURGERY IN COMBINED PHACOVITRECTOMY FOR EYES WITH DENSE VITREOUS HEMORRHAGES

PURPOSE

To investigate the efficacy and safety of a primary core vitrectomy technique for combined phacovitrectomy in eyes showing a poor red reflex because of dense vitreous hemorrhage before cataract surgery.

METHODS

A total of 156 eyes from 156 patients, who underwent combined phacovitrectomy because of cataract and dense vitreous hemorrhage, and who were followed up for at least 6 months were included. The patients were divided into a primary phacoemulsification group (Group A, 80 eyes) who underwent phacoemulsification first followed by total vitrectomy and a primary vitrectomy group (Group B, 76 eyes) who underwent core vitrectomy first followed by cataract surgery and followed by total vitrectomy. A conventional 23-gauge combined phacovitrectomy was performed in all patients. The operation time, including the total continuous curvilinear capsulorhexis time and total cataract surgery time, and the incidence of surgery-related complications were evaluated in the two groups.

RESULTS

Diabetic retinopathy was the most common cause for vitreous hemorrhage in both groups (Group A: 51 eyes; Group B: 39 eyes). The total continuous curvilinear capsulorhexis time (P = 0.001) and total cataract surgery time (P = 0.036) were significantly shorter in Group B than in Group A. Among the complications, radial tears occurred more frequently in Group A than Group B, but these differences were not statistically significant (P = 0.211). Pupil size reduction during cataract surgery was greater in Group B than in Group A (P = 0.034). There were no significant differences in posterior capsular ruptures or posterior capsular opacities between the two groups. Other postoperative complications were not observed in either group until 6 months after surgery.

CONCLUSION

Primary core vitrectomy combined with phacovitrectomy of patients who had dense vitreous hemorrhage helped to obtain a good red reflex and enabled surgeons to perform successful cataract surgery. In addition, primary core vitrectomy was an easy and safe technique, which reduced the surgery time and surgery-related complications. This surgical technique would, therefore, be helpful to vitreoretinal surgeons.

Complications of cataract surgery in eyes filled with silicone oil

INTRODUCTION

The aim of the study was to evaluate complications of cataract surgery in eyes filled with silicone oil.

METHODS

This retrospective, noncomparative, consecutive case series analyzed medical files of patients with eyes filled with silicone oil undergoing cataract surgery. Phacoemulsification with posterior chamber intraocular lens implantation was conducted with or without concurrent silicone oil removal.

RESULTS

In this study, 121 eyes of 120 patients were included. In 32 eyes (26.4%) with evident silicone oil microemulsification or silicone oil-associated open-angle glaucoma, silicone oil was removed prior to phacoemulsification through a pars plana incision and no cases of posterior capsular rupture occurred during the subsequent cataract surgery. In the remaining 89 eyes, phacoemulsification was performed with silicone oil in the vitreous cavity. In these eyes, the rate of posterior capsular rupture was 9/89 (10.1%) and the rate of silicone oil migration into the anterior chamber through an apparently intact posterior capsule was 5/89 (5.6%). In 94 eyes (77.7%), an intraocular lens was inserted into the capsular bag, in 3 eyes (2.5%) into the sulcus, and in 1 eye (0.8%) a transscleral suturing was performed.

CONCLUSIONS

In this series, complications related to the silicone oil were not uncommon during cataract surgery. In the majority of patients without evident silicone oil microemulsification or silicone oil-associated open-angle glaucoma, cataract surgery and posterior chamber intraocular lens implantation were performed while leaving the silicone oil in place.

Clinical Complications of Combined Phacoemulsification and Vitrectomy for Eyes with Coexisting Cataract and Vitreoretinal Diseases

Purpose

To discuss the intraoperative and postoperative complications of combining phacoemulsification and foldable intraocular lens (IOL) implantation with pars plana vitrectomy in eyes with significant cataract and coexisting vitreoretinal diseases.

Methods

This retrospective study consisted of 186 eyes of 149 patients with various vitreoretinal abnormalities and visually significant cataracts. Vitreoretinal surgery was combined with clear corneal phacoemulsification and foldable IOL implantation. Main outcome measures were the intraoperative and postoperative complications at from 6 to 56 months.

Results

The most common intraoperative complication was iatrogenic retinal hole (5.3%), transient corneal edema (3.2%), and posterior capsule break (2.1%). The most common postoperative complication was posterior capsule opacification (21.5%) and elevated intraocular pressure (9.7%), macular edema (8.1%), fibrinous reaction (6.9%), vitreous hemorrhage (3.7%), posterior synechiae (3.7%), and recurrent retinal detachment (3.2%). Postoperatively, in 162 eyes (87.1%), visual acuity improved by 3 lines or more on the Snellen chart. In 14 eyes (7.5%), vision remained within 3 lines of preoperative levels and in 10 eyes (5.3%), vision had decreased at the last follow-up.

Conclusions

Postoperative complications did not increase significantly in the combined phacoemulsification and vitreoretinal surgery. Combined vitreoretinal surgery and phacoemulsification with foldable IOL implantation is safe and effective in treating vitreoretinal abnormalities coexisting with cataract. Based on extensive experience with the combined procedure, the authors suggest that combined surgery is recommended in select patients having simultaneous vitreoretinal pathologic changes and cataract.

Phacoemulsification in Previously Vitrectomized Patients: An Analysis of the Surgical Results in 100 Eyes as well as the Factors Contributing to the Cataract Formation

Purpose

To evaluate the safety and effectiveness of phacoemulsification with clear corneal incision in previously vitrectomized patients as well as factors affecting the development time and type of cataract occurring after pars plana vitrectomy (PPV).

Methods

The authors conducted a prospective study of 100 consecutive eyes of patients who developed a cataract after PPV. Three groups were established based on the underlying vitreoretinal pathology. The main outcome measurements were intraoperative and postoperative complications and changes in best-corrected visual acuity (BCVA).

Results

The median interval between PPV and phacoemulsification was 11.5 months. Patients with proliferative diabetic retinopathy required phacoemulsification earlier (p=0.018). Posterior subcapsular cataracts developed more frequently in patients <50 years (73.7%, p=0.000) and affected those who underwent vitrectomy primarily for complicated retinal detachment (48.8%, p=0.046). Intraoperative complications included posterior capsular tears (4%), luxated nucleus into vitreous (2%), and zonular dialysis (5%). Postoperative complications were vitreous hemorrhage (6%), retinalredetachment (4%), pupillary synechiae (6%), ocular hypertension (4%), and Seidel phenomenon (3%). Posterior Nd:YAG laser capsulotomy was required in 44% of eyes. BCVA was improved in 85% of cases at the end of follow-up (median, 15.5 months). Twenty-one patients with one functioning eye (61.9%) demonstrated visual improvement compared with 79 patients with bilateral vision (91.1%; p=0.003).

Conclusions

The technique allows stable improvement in BCVA through long follow-ups. It is more risky than in nonvitrectomized eyes. The visual results after phacoemulsification in vitrectomized eyes seem to be limited by retinal comorbidity and surgical complications.

Surgical Results of Combined Pars Plana Vitrectomy, Phacoemulsification, and Intraocular Lens Implantation for various Vitreoretinal Diseases

PURPOSE

To evaluate the results and complications of combined pars plana vitrectomy (PPV), phacoemulsification and aspiration (PEA), and intraocular lens (IOL) implantation.

METHODS

A total of 117 eyes from 114 patients who had undergone PPV combined with PEA and IOL implantation were retrospectively analyzed. Combined surgery was performed for a wide variety of vitreoretinal diseases. Intraoperative and postoperative complications were also reviewed.

RESULTS

The postoperative BCVA improved by 2 lines or more in 85 eyes (72.6%). Intraoperative complications consisted of retinal tears in 14 eyes (12.0%) and posterior capsular rupture in 2 eyes (1.7%). Iatrogenic retinal tears occurred more frequently in eyes with a macular hole than in eyes with any other disease (p=0.005, chi-square test). Postoperative complications consisted of posterior capsule opacification (PCO) (21 eyes), transient IOP elevation (29 eyes), vitreous hemorrhage (6 eyes), anterior chamber fibrin exudation (11 eyes), posterior iris synechia (8 eyes), neovascular glaucoma (1 eye), and recurrent retinal detachment (RD) (2 eyes). Fibrin exudation occurred more frequently in eyes with proliferative diabetic retinopathy (PDR) and RD than in eyes with any other disease (p=0.03, chi-square test). PCO occurred more frequently in eyes with PDR than in eyes with any other disease (p=0.03, chi-square test).

CONCLUSIONS

The present study suggests that a high success rate can be achieved when recently improved PPV techniques are combined wi th PEA and IOL implantation. The complications that were observed following this combined treatment varied with respect to the vitreoretinal disease present prior to surgery.

The Incidence and Risk Factors of Lens-iris Diaphragm Retropulsion Syndrome during Phacoemulsification

PURPOSE

In the present study, the incidence and risk factors of lens-iris diaphragm retropulsion syndrome (LIDRS) were evaluated.

METHODS

Patients who underwent cataract surgery using phacoemulsification between June 2014 and December 2014 were included in the study. The preoperative ocular biometric and intraoperative surgical parameters were examined. The incidence of LIDRS and various risk factors were analyzed using an independent t-test, Pearson's chi-square test, and univariable and multivariable logistic regression analyses.

RESULTS

Among 124 eyes of 124 patients, 100 (80.6%) had no LIDRS and 24 (19.4%) had LIDRS. LIDRS occurred in 13 of 31 vitrectomized eyes (41.9%) and 11 of 93 non-vitrectomized eyes (11.8%). Based on univariable analysis, age (odds ratio [OR], 0.920; p = 0.001), vitrectomized eye (OR, 5.038; p = 0.001), spherical equivalent (OR, 0.778; p < 0.001), axial length (OR, 1.716; p < 0.001), anterior chamber depth (OR, 3.328; p = 0.037), and 3.0 mm vs. 2.2 mm incision size (OR, 4.964; p = 0.001) were statistically significant risk factors associated with the development of LIDRS. Conditional multivariable logistic regression showed that vitrectomized eye (OR, 3.865; 95% confidence interval [CI], 1.201 to 12.436; p = 0.023), long axial length (OR, 1.709; 95% CI, 1.264 to 2.310; p = 0.001), and 3.0 vs. 2.2 mm incision size (OR, 3.571; 95% CI, 1.120 to 11.393; p = 0.031) were significant independent risk factors associated with LIDRS.

CONCLUSIONS

LIDRS is a relatively common occurrence and was found to be associated with vitrectomized eye, long axial length, and larger incision size. Evaluating risk factors prior to cataract surgery can help reduce associated morbidity.

Surgical and visual outcome following 20-gauge vitrectomy in proliferative diabetic retinopathy over a 10-year period, evidence for change in practice

INTRODUCTION

The study reports 10-year anatomical and visual outcome in patients who underwent pars plana vitrectomy (PPV) for complications due to proliferative diabetic retinopathy (PDR).

METHODS

Retrospective analysis of patients undergoing 20 G PPV from January 1999 to May 2010 for tractional retinal detachment (TRD) and non-clearing vitreous hemorrhage (NCVH) secondary to PDR recorded prospectively on an electronic patient record. The primary aim was to study anatomical success and eyes with visual acuity (VA) of ≤ 0.3 logMAR at last follow-up.

RESULTS

There were 346 eyes of 249 patients with mean age of 55.63 years and follow-up of 1.44 years. In all, 95.3% of eyes had a flat retina at final follow-up. Overall 136/346 (39.4%) eyes had final VA of logMAR ≤ 0.3 (Snellen 6/12) and 129 (37.3%) had logMAR ≥ 1.0 (Snellen 6/60). In all, 50/181 (27.6%) eyes with TRD and 84/165 (50.9%) with NCVH achieved final VA of ≤ 0.3 logMAR (Snellen 6/12). A total of 218 (63.1%) showed ≥ 0.3 logMAR improvement from baseline to last follow-up. Both preoperative VA and final postoperative (post-op) VA (P<0.001) improved significantly with each year from 1999 to 2010. The commonest peroperative complication was iatrogenic retinal tear formation (28.4%). This was a risk factor for the development of post-op retinal detachment, odds ratio: 3.90 (95% confidence interval: 1.91-7.97, P = 0.0002). Silicone oil was used in 5.2% of patients at the primary procedure. In all, 9.2% required removal of non clearing post vitrectomy hemorrhage.

CONCLUSIONS

Outcomes from vitreoretinal surgery for complications of diabetic retinopathy have improved. In addition, the visual outcome after diabetic vitrectomy steadily improved over the 10-year period, which may in part be due to the move to operate on patients with better vision.

Outcome of phacoemulsification in previously vitrectomized myopic eyes with axial length greater than 26 mm

PURPOSE

To determine the outcome, including the intraoperative and postoperative complications, of phacoemulsification with intraocular lens (IOL) implantation in myopic eyes with axial length of 26 mm or more that had undergone previous pars plana vitrectomy (PPV).

METHODS

This prospective study comprised 37 highly myopic eyes (axial length over 26 mm) with previous vitrectomy that underwent phacoemulsification and were reviewed at a mean postoperative follow-up of 3-6 weeks. The main outcome measures were preoperative and postoperative spherical equivalent, preoperative and postoperative visual acuity, difference between intended and achieved refraction, and any complications during cataract surgery.

RESULTS

The mean age for cataract surgery was 61.5 years. Nuclear sclerosis was present in 91.89% of patients. The mean axial length was 27.53 mm (range 26.03-30.52 mm). The most common indication for vitrectomy in our study was retinal detachment surgery (35 out of 37). Postoperatively, 34 patients (91.89%) had a visual acuity improvement of 2 or more Snellen lines and the best-corrected visual acuity at final refraction was 6/9 (0.2 logMAR) or better in 30 patients (81.08%). Two patients had perioperative complications (5.4%).

CONCLUSIONS

Cataract surgery with IOL implantation can be performed safely in highly myopic eyes after PPV and the final visual acuity outcomes appear to be dependent on the preoperative status of the retina. Our study suggests that the incidence of intraoperative and postoperative complications can be reduced to a minimum with proper planning and meticulous attention to detail during cataract surgery.

Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans

PURPOSE

To investigate the prevalence and predictors of intraoperative and 90-day postoperative ocular complications associated with cataract surgery performed in the United States Veterans Health Administration (VHA) system.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Forty-five thousand eighty-two veterans who underwent cataract surgery in the VHA.

METHODS

The National Patient Care Database was used to identify all VHA patients who underwent outpatient extracapsular cataract surgery and who underwent only 1 cataract surgery within 90 days of the index surgery between October 1, 2005, and September 30, 2007. Data collected include demographics, preoperative systemic and ocular comorbidities, intraoperative complications, and 90-day postoperative complications. Adjusted odds ratios (ORs) of factors predictive of complications were calculated using logistic regression modeling.

MAIN OUTCOME MEASURES

Intraoperative and postoperative ocular complications within 90 days of cataract surgery.

RESULTS

During the study period, 53786 veterans underwent cataract surgery; 45082 met inclusion criteria. Common preoperative systemic and ocular comorbidities included diabetes mellitus (40.6%), chronic pulmonary disease (21.2%), age-related macular degeneration (14.4%), and diabetes with ophthalmic manifestations (14.0%). The most common ocular complications were posterior capsular tear, anterior vitrectomy, or both during surgery (3.5%) and posterior capsular opacification after surgery (4.2%). Predictors of complications included: black race (OR, 1.38; 95% confidence interval [CI], 1.28-1.50), divorced status (OR, 1.10; 95% CI, 1.03-1.18), never married (OR, 1.26; 95% CI, 1.14-1.38), diabetes with ophthalmic manifestations (OR, 1.33; 95% CI, 1.23-1.43), traumatic cataract (OR, 1.80; 95% CI, 1.40-2.31), previous ocular surgery (OR, 1.29; 95% CI, 1.02-1.63), and older age.

CONCLUSIONS

In a cohort of United States veterans with a high preoperative disease burden, selected demographic factors and ocular comorbidities were associated with greater risks of cataract surgery complications. Further large-scale studies are warranted to investigate cataract surgery outcomes for non-VHA United States patient populations.

Phacoemulsification in vitrectomized eyes: results using a 'phaco chop' technique

PURPOSE

To evaluate the intraoperative and early postoperative complications of phacoemulsification using a 'phaco chop' technique in previously vitrectomized eyes.

METHODS

A prospective interventional case series. Seventy-five previously vitrectomized eyes of 73 consecutive patients underwent phacoemulsification using a 'phaco chop' technique via clear corneal incision. Patients were observed for any intraoperative or early postoperative complications.

RESULTS

Fifty-four eyes (72%) had predominant nuclear sclerosis or posterior subcapsular cataract. The intraoperative findings included intraoperative miosis [seen in 21 eyes (28%)] and posterior capsule plaques [in 15 eyes (20%)]. No other significant intraoperative complication (posterior capsule rupture, zonular lysis or dropped nuclei) was observed. In the early postoperative period, one patient had massive serous choroidal detachment, which resolved with conservative treatment. Mean preoperative visual acuity (LogMar scale) was 0.74, which improved to 0.36 postoperatively (p < 0.001).

CONCLUSION

Phacoemulsification using a 'phaco chop' technique is a safe procedure in vitrectomized eyes.

Diabetic vitrectomy: the influence of lens status upon surgical outcomes

PURPOSE OF REVIEW

Management of the lens in diabetic eyes undergoing vitrectomy has long been a source of controversy. Initially, the lens was removed during diabetic vitrectomy because of intraoperative changes. It was noted, however, that anterior segment neovascular complications were greater in aphakic eyes after diabetic vitrectomy, and subsequently the vitreoretinal surgeon attempted to spare the lens. Lens management in this regard continues to attract discussion. This report reviews recent trends in the management of the native lens in the diabetic eye undergoing vitrectomy.

RECENT FINDINGS

The rate of cataract formation after diabetic vitrectomy is high in eyes left phakic. The rates of anterior segment neovascularization and retinal detachment after diabetic vitrectomy are similar in phakic and nonphakic eyes. The rate of subsequent reoperation after diabetic vitrectomy may be greater in eyes left phakic.

SUMMARY

Although the management of the lens in an eye undergoing diabetic vitrectomy should be individualized, cataract extraction performed either before or in combination with vitrectomy may reduce the rate of subsequent reoperation. The vitreoretinal surgeon may consider rendering an eye nonphakic before or during diabetic vitrectomy to optimize outcomes.

Cataract surgery in previously vitrectomized eyes

PURPOSE

To evaluate the results of extracapsular cataract extraction (ECCE) and phacoemulsification (PHACO) performed in previously vitrectomized eyes.

MATERIAL AND METHOD

In this retrospective study, 56 vitrectomized eyes that had ECCE and 60 vitrectomized eyes that had PHACO were included in the study group while 65 eyes that had PHACO in the control group. The evaluated parameters were the incidence of intra-operative and postoperative complications (IPC) and visual outcomes. Chi-squared, independent samples and paired samples tests were used for comparing the results.

RESULTS

Deep anterior chamber (AC) was significantly more common in the PHACO group of vitrectomized eyes (PGVE) and observed in eyes that had undergone extensive vitreous removal (p < 0.05). Except for this there were no significant differences in the rate of IPC between the ECCE group and the PGVE (p > 0.05). Some of the intra-operative conditions such as posterior synechiae, primary posterior capsular opacification (PCO) and postoperative complications such as retinal detachment (RD), PCO were significantly more common in vitrectomized eyes than the controls (p < 0.05). There was no significant difference in the visual acuity gain between the ECCE group and the PGVE (p > 0.05).

CONCLUSION

Deep AC is more common in eyes with extensive vitreous removal during PHACO than ECCE. Decreasing the bottle height is advised in this case. Except for this, the results of ECCE and PHACO are similar in previously vitrectomized eyes. Posterior synechiaes, primary and postoperative PCO and RD are more common in vitrectomized eyes than the controls.

Phacoemulsification in vitrectomized eyes under topical anesthesia

PURPOSE

To study phacoemulsification in vitrectomized eyes under topical anesthesia, assessing anesthetic and intraoperative characteristics and complications.

METHODS

A prospective study was performed on 52 eyes of 51 patients who underwent phacoemulsification of cataract with intraocular lens implantation under topical anesthesia, having previously undergone pars plana vitrectomy. Surgical and anesthetic observations and complications were recorded, as were visual outcomes.

RESULTS

Ninety-two percent of patients had improved visual acuity postoperatively with only one patient having visual loss as a result of surgery. The most common intraoperative observations were of a deep anterior chamber, posterior capsular plaques, posterior synechiae, and nuclear sclerotic cataracts. Topical anesthesia proved satisfactory in 96%, with only two patients requiring intracameral lignocaine 1%; no patients required conversion to injection anesthesia. There were no major operative or postoperative complications.

CONCLUSIONS

Phacoemulsification in vitrectomized eyes can be challenging, but is visually rewarding. Topical anesthesia proved satisfactory for the vast majority of cases, with none of our patients requiring conversion to injection anesthesia.

Diabetic Vitrectomy

OBJECTIVE

To determine the effect of lens status upon the anatomic and visual results in primary diabetic vitrectomy.

DESIGN

Retrospective, comparative, consecutive case series.

PARTICIPANTS

One hundred two eyes of 85 patients with proliferative diabetic retinopathy and its complications that underwent primary vitrectomy.

METHODS

The eyes that remained phakic after vitrectomy were compared with the eyes that were either aphakic or pseudophakic (nonphakic) postoperatively.

MAIN OUTCOME MEASURES

Intraoperative and postoperative complications, vitreoretinal reoperation rate, and ultimate anatomic and visual success with at least 6 months' follow-up.

RESULTS

Preoperatively, 72 eyes were phakic, and 30 were aphakic (n = 1) or pseudophakic (n = 29). During vitrectomy, 1 eye underwent lensectomy and 12 eyes underwent phacoemulsification with lens implantation. Postoperatively, 59 eyes were phakic and 43 eyes were nonphakic. The vitreoretinal reoperation rate was significantly higher (P = 0.04) for the phakic group (28.8%) than for the nonphakic group (11.6%). Rubeosis iridis developed in 3 phakic eyes and no nonphakic eyes (P = 0.26). Intraoperative complications were similar in the phakic and nonphakic groups (P = 0.40). Postoperative complications such as rhegmatogenous retinal detachment (P = 0.39), nonclearing vitreous hemorrhage (P = 0.07), and anterior chamber complications (P = 0.60) were also similar. Visual acuity improved by at least 0.2 logarithm of the minimum angle of resolution units in 76.2% of the phakic eyes and 86.0% of the nonphakic eyes (P = 0.22).

CONCLUSIONS

Eyes that were phakic after primary diabetic vitrectomy had a significantly higher subsequent vitreoretinal reoperation rate when compared with nonphakic eyes, suggesting that diabetic eyes are less likely to require additional vitreoretinal surgery if they are rendered nonphakic before or during vitrectomy.

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.

Stabilization of anterior chamber depth during phacoemulsification cataract surgery in vitrectomized eyes

Abnormal fluctuations in anterior chamber (AC) depth including deepening and mydriasis with paradoxical shallowing and miosis have been described during phacoemulsification cataract surgery in previously vitrectomized eyes. Contributory factors include zonular laxity and reduction of vitreous volume. This report describes a technique to stabilize AC depth and allow safer sculpting and removal of lens matter.

Combined Pars Plana Vitrectomy and Phacoemulsification With Intraocular Lens Implantation in Severe Proliferative Diabetic Retinopathy

BACKGROUND AND OBJECTIVE

To evaluate the results of combined vitrectomies and intraocular lens implantations in cases of proliferative diabetic retinopathy.

PATIENTS AND METHODS

Data from procedures on 117 eyes (91 patients) undergoing combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation for the complications of proliferative diabetic retinopathy were analyzed retrospectively. Follow-up ranged from 8 to 64 months (median = 25 months).

RESULTS

Retinal tears were the most frequent intraoperative problems (19%). Limited postoperative fibrin formation occurred in 22% of eyes. Within 6 months, 7% developed glaucoma and 2% showed new anterior segment rubeosis. Overall, 10% underwent secondary surgical procedures as follows: lavage for hemorrhage (n = 3), silicone oil exchange after 7 days for focal rebleeding (n = 1), silicone oil surgery for retinal detachment after gas resorption (n = 1), and lavage for late vitreous hemorrhage (7 to 13 months) (n = 4). Half of the secondary procedures were necessitated within 3 months of the original surgery.

CONCLUSIONS

Combined surgery in proliferative diabetic retinopathy is safe and effective. It should be considered when lens opacities are either present or likely to develop soon.

Management of lens-iris diaphragm retropulsion syndrome during phacoemulsification

Lens-iris diaphragm retropulsion syndrome (LIDRS) occurs more often than recognized during small-incision phacoemulsification. This syndrome requires an infusion of fluid into the anterior chamber and is characterized by posterior displacement of the lens-iris diaphragm, marked deepening of the anterior chamber, posterior iris bowing, pupil dilation, and often significant patient discomfort. Using microendoscopy, we have observed that LIDRS is essentially a reverse pupillary block. We describe a surgical technique to mechanically break the iridocapsular block to restore normal chamber depth, relieve patient discomfort, and allow the surgeon to proceed safely with phacoemulsification.

Cataract surgery results after pars plana vitrectomy

Continuous refinements in vitreoretinal surgical techniques and an increasing number of posterior segment disorders are being successfully managed with pars plana vitrectomy (PPV). This has resulted in an increase in the number of vitrectomized eyes seen by cataract surgeons. Cataract surgery in previously vitrectomized eyes has been reported to be more challenging than in eyes without previous vitrectomy. Special considerations and precautions are often required before, during, and after the surgery to successfully address these challenges. Several studies have reported that phacoemulsification with intraocular lens implantation after PPV is a relatively safe procedure that can improve visual acuity and quality of life. The extent of visual improvement may be limited only by retinal comorbidity.

Phacoemulsification and intraocular lens implantation following pars plana vitrectomy: a prospective study

AIMS

To examine the intraoperative characteristics of phacoemulsification in eyes that had undergone pars plana vitrectomy and to determine complication rates and visual outcomes.

METHODS

A prospective study of 45 consecutive cataract operations on vitrectomised eyes performed over a 9-month period by a single surgeon. Data were collected on preoperative characteristics, intraoperative observations and complications, postoperative complications, and visual acuities.

RESULTS

Zonular laxity with abnormal deepening of the anterior chamber and mydriasis was noted in six eyes that had undergone extensive vitreous removal for the treatment of retinal detachment or proliferative diabetic retinopathy, but not in eyes that had had limited 'core vitrectomy' such as for macular hole or epiretinal membrane. In two eyes, the initial deepening of the anterior chamber was accompanied by paradoxical shallowing with miosis (the 'infusion deviation syndrome'). Sight-threatening complications were rare. Snellen visual acuity improved in 84.6% of eyes previously treated for 'macular hole, 85.7% of eyes treated for 'macula-on' retinal detachment, 66.7% of eyes treated for 'macula-off' retinal detachment, and 57.1% of eyes treated for diabetic retinopathy.

CONCLUSIONS

Surgeons need to be aware of additional challenges arising from zonular instability in eyes that have had extensive vitreous removal. A lower infusion bottle height may guard against sudden changes in anterior chamber depth. The use of a corneal tunnel avoids difficulties associated with an unusually deep anterior chamber. Visual acuity is less likely to improve in patients previously treated for diabetic retinopathy or for macula-off retinal detachment.

Nucleus cryoinversion for extraction of highly complicated cataracts

We describe a technique for cataract extraction in vitrectomized eyes that uses secured removal of the nucleus with no manipulation of the capsular bag. After a large scleral tunnel is prepared and a capsulorhexis created, a 20-gauge retinal cryoprobe enveloped in a plastic or a silicone sleeve is introduced into the anterior chamber. The cryoprobe engages the nucleus by a "freeze-grip" and rotates it 180 degrees so that the nucleus is elevated into the anterior chamber with no force applied to the capsule and the cryoprobe supporting it from below. The cryoprobe is replaced by a vectis under the nucleus and with the help of another instrument from above, the nucleus is removed. Aspiration of cortical material under low-pressure fluid maintenance of the anterior chamber completes removal of the cataract. An intraocular lens is then implanted in the ciliary sulcus for maximum capsule support.

Results of cataract surgery in previously vitrectomized eyes

PURPOSE

To evaluate the difficulties and results of manual extracapsular cataract extraction (ECCE) and phacoemulsification cataract surgery performed in previously vitrectomized eyes.

SETTING

Pécs University of Sciences, Faculty of Medicine, Department of Ophthalmology, Pécs, Hungary.

METHODS

This retrospective case-control study comprised a series of 84 cataract extractions with or without intraocular lens implantation. Forty-three patients had manual ECCE and 41, phacoemulsification. The intraoperative and postoperative complications and visual outcomes in the 2 groups were analyzed and compared.

RESULTS

Cataract extractions were performed a mean of 15.8 months (range 1 to 86 months) after the pars plana vitrectomy. The indications for vitrectomy were diabetic retinopathy, retinal detachment, proliferative vitreoretinopathy, giant retinal tear, macular hole, eye trauma, vitreous hemorrhage after central retinal vein occlusion, and uveitis. Primary posterior capsule fibrosis was the most common intraoperative complication, occurring in 24% of eyes. Posterior capsule rupture occurred in 5 eyes in the ECCE group and 3 in the phacoemulsification group. Zonulysis occurred in 2 and 1 eyes, respectively. A dropped nucleus occurred in 3 cases in the phacoemulsification group. Posterior capsule opacification and secondary glaucoma were the most common postoperative complications, occurring in 5 and 3 cases in the ECCE group, respectively, and in 3 and 4 cases in the phacoemulsification group. Visual acuity 6 weeks postoperatively improved or remained within 2 Snellen lines in 95% of eyes, which is comparable to data in the recent literature.

CONCLUSIONS

Phacoemulsification gave better results than manual ECCE in previously vitrectomized eyes. Underlying retinal disease limited the final visual acuity.

Outcome of phacoemulsification after pars plana vitrectomy

PURPOSE

To compare the outcome of phacoemulsification surgery in patients with and without prior vitrectomy, adjusted for confounding factors.

DESIGN

Retrospective cohort study.

PARTICIPANTS AND CONTROLS

Thirty-one consecutive eyes undergoing phacoemulsification after pars plana vitrectomy (PPV) and 116 consecutive eyes undergoing phacoemulsification without previous PPV.

METHODS

Office records of the operating surgeons were reviewed for age, gender, type of cataract, vitrectomy status, best-corrected visual acuity (BCVA) before and after phacoemulsification, intraoperative difficulties, and postoperative complications. Bivariate analyses between these predictors and the main outcome, BCVA of 20/40 or better after phacoemulsification, were performed using Pearson's chi-square tests. An adjusted analysis of the relationship between outcome and vitrectomy status was performed with logistic regression. Pearson's chi-square tests were used to compare type of cataract, intraoperative difficulties, and postoperative complications in study and control eyes.

MAIN OUTCOME MEASURES

BCVA of 20/40 or better after phacoemulsification, rates of intraoperative difficulties, and postoperative complications.

RESULTS

The most common indication for PPV was macular hole. The average interval from PPV to phacoemulsification was 15.4 months. Study eyes were followed for an average of 10 months compared with 6.6 months for controls. Study eyes were more likely than controls to have predominantly nuclear sclerotic cataracts (P = 0.002). After cataract extraction, 24 of 31 study eyes (77.4%) and 110 of 116 control eyes (94.8%), had BCVAs of 20/40 or better. After adjusting for confounders, eyes without previous vitrectomy were 3.44 times more likely to obtain a BCVA of 20/40 or better than eyes with prior PPV, but this difference was not statistically significant (95% CI, 0.72-16.67). Only 3 of 31 (9.7%) study and 11 of 116 (9.4%) control eyes had intraoperative difficulties (P = 0.47). Posterior capsule plaque was the most common intraoperative difficulty in study eyes; small pupil requiring stretching or iris hooks was most common in controls. Only 1 of 31 (3.2%) study eyes had a postoperative complication other than posterior capsule opacification compared with 18 of 116 (15.5%) controls (P = 0.07).

CONCLUSIONS

A large proportion of patients with prior PPV obtain good visual acuity after phacoemulsification. We did not find significantly higher rates of intraoperative difficulties or postoperative complications compared with controls. The benefits of phacoemulsification seem to be limited only by retinal comorbidity.

Results of combined vitreoretinal surgery and phacoemulsification with intraocular lens implantation

PURPOSE

To assess the outcome and complications after combined pars plana vitrectomy and phacoemulsification with intraocular lens implantation in patients with concomitant cataract and vitreoretinal abnormalities.

METHODS

This retrospective study consisted of 113 eyes of 109 patients with various vitreoretinal abnormalities and visually significant cataract. Vitreoretinal surgery was combined with clear corneal phacoemulsification and intraocular mplantation.

RESULTS

The combined surgery resulted in minimal complications, and postoperative visual acuity was improved in 83 eyes (71.6%). Visual acuity was improved by two or more lines in 26 eyes (66.6%) with proliferative diabetic retinopathy, 22 eyes (73%) with proliferative vitreoretinopathy, eight eyes (30.7%) with macular abnormalities, four eyes (55.5%) with trauma and two eyes (40%) with retinal vein occlusion.

CONCLUSIONS

The combined vitreoretinal surgery and phacoemulsification with intraocular lens implantation was safe and effective in treating vitreoretinal abnormalities coexisting with cataract. Combined surgery is recommended for all patients having simultaneous vitreoretinal pathological changes and cataract. The addition of phacoemulsification does not prolong vitreoretinal operative time notably nor increase the risk of intraoperative and postoperative complications significantly

Assessment of nuclear sclerosis after nonvitrectomizing vitreous surgery

PURPOSE

Nuclear sclerosis develops frequently after successful pars plana vitrectomy. We evaluated changes in the degree of nuclear sclerosis after nonvitrectomizing vitreous surgery for idiopathic epimacular proliferation.

METHODS

Forty-one consecutive patients (41 eyes) underwent removal of idiopathic epimacular proliferation by nonvitrectomizing vitreous surgery and were followed postoperatively for at least 12 months. Visual acuity, refractive error, slit-lamp biomicroscopy, and Scheimpflug photographs were assessed preoperatively and postoperatively to evaluate changes in the degree of lenticular opacification. Quantitative analysis of the nuclear sclerosis was performed by densitometry with Scheimpflug photographs performed on only the last 21 patients. We evaluated these measurements by comparing statistically the preoperative and postoperative difference between both eyes (operative eye minus nonoperative ocular data).

RESULTS

There was no significant difference in the progression of nuclear sclerosis or degree of myopic shift between the operated and fellow eyes during postoperative follow-up (mean +/- SD, 22 +/- 8 months; median, 22 months; range, 12 to 48 months). The average preoperative and postoperative refractive errors in operated eyes were 0.0 +/- 2.4 diopters and 0.1 +/- 2.5 diopters, respectively; the average difference in the refractive errors between both eyes was -0.2 +/- 0.7 diopter preoperatively and -0.2 +/- 0.9 diopter postoperatively (P =.961, paired t test). The average preoperative and postoperative nuclear density values by Scheimpflug photography in 21 operated eyes were, respectively, 72 +/- 18 nuclear density units and 75 +/- 17 nuclear density units; the average difference in nuclear density values between both eyes was -1 +/- 4 nuclear density units preoperatively and 0 +/- 6 nuclear density units postoperatively (P =.631, paired t test).

CONCLUSION

Progression of nuclear sclerotic cataract based on changes in refractive error and Scheimpflug photography was not observed after nonvitrectomizing vitreous surgery.

Phacoemulsification in eyes with past pars plana vitrectomy: case-control study

PURPOSE

To determine intraoperative and postoperative complications and outcomes of phacoemulsification of cataract in eyes that had previous pars plana vitrectomy.

SETTING

University-based anterior segment disease referral practice.

METHODS

This was a retrospective case-control study of a surgical series of 52 consecutive postvitrectomy cataract extractions statistically compared with control eyes from the same practice.

RESULTS

Cataract extraction followed vitrectomy by 2 months to 6 years (mean 19 months). Cataracts with a posterior subcapsular component were seen more frequently in postvitrectomy eyes (58% versus 25% in control eyes). Cataract extraction after pars plana vitrectomy was often more challenging than in control eyes. Challenges included unstable posterior capsules, loose zonules, and posterior capsule plaque. Postoperative posterior capsule opacification (PCO) was more common in study than in control eyes (51% versus 21%; P = .002), especially if expandable gas or silicone oil had been used at vitrectomy. Visual acuity improved in 87% of study eyes, with 46% achieving a visual acuity of 20/40 or better. In study eyes in which the indication for vitrectomy was macular hole or epiretinal membrane, nuclear sclerosis was the most common cataract type, no intraoperative complications occurred, the PCO rate was low (13%), and visual acuity was better (73% 20/40 or better) than in the other study eyes.

CONCLUSION

Phacoemulsification after pars plana vitrectomy can be performed with a low complication rate and with good visual results, although limited by underlying retinal disease. Posterior capsule opacification requiring neodymium: YAG capsulotomy was common in this series.