Combined cataract and vitreoretinal surgery

Combined pars plana vitrectomy and cataract surgery is a safe and effective procedure that allows the surgeon to avoid a second operation, but adequate treatment is recommended to all patients over 60 years, Dr Gisbert Richard, MD, told delegates on Sunday, Day 3 of the ESCRS 2009 Congress.

“Development or progression of cataract is a frequent postoperative complication after Pars Plana Vitrectomy (PPV) for macular holes, the epiretinal membrane and diabetic retinopathy in the elderly,” said Dr. Richard.

“So combining PPV and cataract surgery may be indicated, especially in older patients.”

He said that PPV offered good visual outcomes and that ambulatory surgery is possible with the technique. There is no influence of IOL diameter on visual outcome, and no increased risk of cataract when used in conjunction with a gas or silicone oil endotamponade.

He noted that the risk of cataract formation after PPV was 74%, but that rose with age. For patients 60 or older, there was a 100% occurrence of cataract after PPV, but for patients below 40 there was an extremely low risk.

He said the combined PPV and cataract surgery required a modified technique for cataract extraction. The anterior chamber is opened via a long corneo-scleral tunnel or a long corneal tunnel. This approach tolerates a pressure increase and allows a sufficiently large opening for cataract surgery.

“Start with the cataract surgery, ensure you construct an extremely precise tunnel of 3.5 or greater millimetres in length,” he said.

He added that the need for small incisions has guided technological development, leading to evolution of phaco techniques and transconjunctival pars plana vitrectromies.

“The result is a reduction in patient discomfort, operation time and surgical trauma,” he said. He also added that it was essential to ensure the complete removal of cortex, and he strongly advised IOL implantation into the capsular bag.

He said results for the technique were good in cases of epiretinal membrane. In a series of 230 patients 82% experienced a two line gain, 7% stayed the same while vision got worse for 11%.

In diabetic retinopathy, the results were more mixed. In a series of 140 patients, 73% had two lines of improvement, 90% had retinal reattachment, while 10% had residual peripheral retina detachment.

Other complications included posterior synechia 1n 13%, iris capture for 3% and vitreous haemorrhage for 10% improved vision.

Overall he said combined PPV and cataract surgery is a safe and effective procedure offering good visual outcomes and recommended for patients 60 years old or more.