Combined Phacoemulsification and Pars Plana Vitrectomy Steven B. Koenig, MD; Dennis P. Han, MD; William F. Mieler, MD; Gary W. Abrams, MD; Glenn J. Jaffe, MD; Thomas C. Burton, MD
\s=b\ Combined phacoemulsification and pars plana vitrectomy were performed in eight eyes with cataract and vitreoretinal disease. Six eyes had tractional retinal detachment and/or nonclearing vitreous hemorrhage, one eye had a retained metallic intraocular foreign body, and one eye had a traumatic retinal detachment. In six eyes, a posterior chamber lens implant was placed in the capsular bag. Postoperative visual acuity improved in each case and ranged between 20/15 and 6/200. There were no perioperative complications, and the posterior chamber lens implant appeared well tolerated during an average follow-up interval of 8 months (range, 3 to 30 months). This technique allows endocapsular fixation of a posterior chamber lens and provides rapid visual rehabilitation with a single operation.
(Arch Ophthalmol. 1990;108:362-364)
often removed during Cataractsplana vitrectomy if are
pars
surgery
they interfere with visualization of the posterior pole. Lensectomy is most commonly performed through the pars plana using a vitreous aspiration-cut¬ ting instrument for lenses with soft nuclei or ultrasonic fragmentation for
cataracts with hard nuclei.1 However, pars plana lensectomy requires exci¬
sion of the anterior and/or posterior lens capsule and precludes endocapsu¬ lar fixation of a posterior chamber in¬ traocular lens. We herein describe a surgical technique that combines pha¬ coemulsification and pars plana vitreeAccepted for publication November 14, 1989.
From the Cornea and Vitreoretinal Services of the Eye Institute, The Medical College of Wisconsin, Milwaukee. Reprint requests to Medical College of Wisconsin, Eye Institute, 8700 W Wisconsin Ave, Milwaukee, WI 53226 (Dr Koenig).
a single operation and allows placement of a posterior chamber lens implant in the capsular bag.
tomy in
PATIENTS AND METHODS
We retrospectively reviewed the charts of eight consecutive patients who underwent combined phacoemulsification and pars plana vitrectomy at our institution between December 1986 and June 1989. Preoperative clinical data included the patient's age, sex, type of cataract, underlying vitreous or retinal disease, and preoperative visual acuity. The duration of insulin dependence was noted in patients with diabetes mellitus. Postoperative data included the best corrected visual acuity, follow-up interval,
and results of the fundus examination. The results of the last postoperative examina¬ tion were recorded. One patient (case 3) was unable to return for a follow-up examina¬ tion; postoperative data were provided by the referring ophthalmologist. Preoperatively, pupils were dilated with frequent drops of 5% phenylephrine hydro¬ chloride (Neo-Synephrine), 1% cyclopentolate hydrochloride (Cyclogyl), and 0.03% flurbiprofen sodium (Ocufen), as well as one drop of 0.25% hydrobromide scopolamine. Surgery was performed following the ad¬ ministration of general endotracheal anes¬ thesia (cases 1, 2, 3, 4, 5, 7, and 8) or mon¬ itored local anesthesia (case 6), which in¬ cluded a facial nerve and retrobulbar block using a 1:1 mixture of 2% lidocaine hydro¬ chloride and 0.75% bupivacaine hydrochlo¬ ride with hyaluronidase. All eyes were prepared for pars plana vitrectomy by placing 4-0 black silk sutures transconjunctivally around the rectus mus¬ cles. A 180° fornix-based conjunctival flap was dissected superiorly. Local bleeding was controlled with wet-field cautery. Scle¬ rotomy sites were marked 3.0 to 3.5 mm posterior to the limbus inferotemporally, superonasally, and superotemporally. A su¬ ture was preplaced for the inferotemporal sclerotomy site, and the vitreous cavity was entered with a 19-gauge microvitreal reti¬ nal blade. An infusion cannula (2.5 mm to
4.0
mm)
was
connected to 500 mL of irri¬
gating solution (balanced salt solution en¬
riched with bicarbonate, dextrose, and gluthathione) containing 0.3 mL of 1:1000 epinephrine hydrochloride and secured in place. In eyes receiving a posterior chamber lens implant (cases 1, 2, 3,4, 6, and 8) a 7.0mm partial-depth corneoscleral incision was
made with a razor blade knife 1 to 2 mm
posterior to the superior limbus. A stab in¬
made within the corneoscleral a 3.2-mm keratome. The ante¬ rior chamber was filled with hyaluronate sodium (Healon). A 6-mm-diameter periph¬ eral puncture ("can opener") anterior cap¬ sulotomy was completed with a 25-gauge bent cystotome needle. The phacoemulsifi¬ cation handpiece was introduced into the anterior chamber and the lens nucleus emulsified in the posterior chamber. Resid¬ ual cortical material was aspirated with the 0.3-mm tip of the irrigation-aspiration in¬ strument. The wound was temporarily closed with a single 7-0 polyglactin 910 (Vi-
cision
was
groove with
cryl)
suture.
Two superiorly located sclerotomies were made with a 19-gauge microvitreal retinal blade, and the endoilluminator and vitrec¬ tomy instrument were introduced. After pars plana vitrectomy and adjunctive pro¬ cedures were performed, the light pipe and vitrectomy instrument were removed from the eye and the sclerotomy sites tempo¬ rarily closed with plugs. The retina was then inspected by indirect ophthalmoscopy. The previously placed polyglactin 910 su¬ ture was removed from the cataract wound and the capsular bag filled with Healon. The corneoscleral wound was enlarged to 7 mm using a corneoscleral scissors. A Sinskeystyle posterior chamber lens implant (IOLAB G107G or 108B, IOLAB Corp, Claremont, Calif) was then placed in the capsu¬ lar bag and centered using a Sinskey hook. The pupil was constricted with intracam¬ eral 0.01% carbachol. The corneoscleral wound was then closed with multiple inter¬ rupted 10-0 monofilament nylon sutures. Prior to completion of the wound closure, residual Healon was removed from the an-
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terior chamber with the 0.3-mm tip of the irrigation-aspiration instrument. Fluidgas exchange was performed in two eyes after extracapsular cataract extraction (case 7) and posterior chamber intraocular lens insertion (case 4). The sclerotomy plugs were removed, and the sites closed with interrupted 7-0 polyglycolic acid (Dexon) sutures. The conjunctival flap was reapproximated with interrupted 7-0 poly¬ glycolic acid sutures. Subconjunctival gentamicin sulfate (20 mg) and dexamethasone sodium phosphate (12 mg) were adminis¬ tered. The eye was treated with topical 1% atropine sulfate and gentamicin ointment prior to patching. Postoperatively, eyes were treated with topical 0.25% scopola¬ mine, 0.3% gentamicin, and 1% prednisolone phosphate. Postoperative visual acuities were mea¬ sured using a soft contact lens (case 5), spectacles (case 1), or a pinhole correction. Postoperative maculopathy was diagnosed by slit-lamp biomicroscopy and a 90-diopter lens or indirect ophthalmoscopy. RESULTS
Six
and two (Table 1). The average age at the time of surgery was 56 years (range, 26 to 74 years). Six eyes had dense vitreous hemorrhages that failed to clear during a period of at least 6 months. Four of these six eyes had long-standing insulin-dependent diabetes mellitus with proliferative retinopathy and had undergone previ¬ ous panretinal or focal argon laser photocoagulation. Two eyes had dia¬ betic tractional retinal detachment (cases 3 and 4). One eye (case 2) had developed neovascularization and vit¬ reous hemorrhage following a branch retinal vein occlusion. None of the eyes in this series exhibited iris neovascu¬ larization. One eye (case 5) had a small retained intravitreal metallic foreign body. One patient (case 7), with a psy¬ chiatric disorder, developed a total rhegmatogenous retinal detachment following self-inflicted blunt ocular
patients
were women
were men
trauma. All eyes in this series had cataracts. Four eyes had immature senile cata¬ racts with mild to moderate nuclear sclerosis (cases 1, 2, 3, and 6), and two eyes (cases 4 and 8) had predominantly
posterior subcapsular or anterior cor¬ tical cataracts. One eye (case 5) devel¬ oped a rosette-shaped posterior sub¬ capsular cataract with anterior corti¬ cal spokes following perforation of the lens with a metallic foreign body. One eye (case 7) had a mature cortical cat¬ aract after blunt trauma. In each case,
the
hazy media (cataract and vitreous hemorrhage) were significant in limit¬ ing visual acuity. Preoperative visual acuity ranged between light percep¬ tion and 20/400.
Table Patient No./
1.—Preoperative Clinical Information*
Vitreoretinal Disease
Age, y/Sex 1/67/M
PDR OS; vitreous heme (7 mo), status post focal argon laser Branch retinal vein
2/70/F
Vision
Cataract
Comments IDDM (30
NS; +2 corti¬ cal; + 1 PSC
y); peripheral neuropathy
+2
+ 3-4
NS; +1 PSC
Possible macular
LP
occlusion OD; vitreous heme
hole
(24 mo) 3/73/F
PDR OD; vitreous
mo); post PRP
heme (9 status
+2
HM at 5 tt
cortical;
IDDM
(20 y)
+ 1 NS IDDM (17
4/35/F
PDR OD; vitreous heme (6 mo);
5/30/M
Retained intraocu¬ lar foreign body
6/74/F
PDR; vitreous heme (6 mo); status post PRP_
7/26/F
Traumatic retinal detachment
+4 cortical
LP
Macula detached
8/69/F
PDR; vitreous heme (6 mo)
+2 PSC
20/200
IDDM
status _
post
+2 cortical; +1 PSC
PRP_
OD
y)
CF at 5 ft
Traumatic with small posterior capsular tear
IDDM
+2 NS; + 1 cortical; + 1 PSC
(22 y)
(6 y)
*PDR indicates proliferative diabetic retinopathy; NS, nuclear sclerosis; IDDM, insulin-dependent diabetes mellltus; PSC, posterior subcapsular; LP, light perception; HM, hand motions; PRP, panretinal photocoagulation; and CF, counting fingers.
Table Patient No.
2.—Postoperative Clinical Information Follow-up,
Visual Retina
Acuity 6/200
Comments
mo
30
20/15
YAG laser
Macular hole
3
20/400 20/50
mo
capsulotomy postoperatively
Diabetic macular edema Diabetic macular edema
Aphakic
soft contact lens correction
20/50
Diabetic macular edema
20/200
Macular
Vitrectomy, macular eplretlnal membrane stripping, capsulectomy
pigmentary
abnormalities 20/40
Diabetic macular edema
Six eyes underwent combined pha¬ pars plana vitrecto¬ my, and insertion of a posterior cham¬ ber intraocular lens (cases 1, 2, 3, 4, 6, and 8). Due to the possibility of post¬
coemulsification,
operative endophthalmitis (case 5) or recurrent retinal detachment (case 7), two eyes did not receive lens implants. Following phacoemulsification, all cor¬ neas remained clear; however, during pars plana vitrectomy, one eye (case 5) developed exposure keratopathy and required epithelial débridement for adequate visualization of the posterior pole. In addition to pars plana vitrec¬ eyes underwent retinal membrane stripping (cases 3 and 4), five eyes underwent argon laser en-
tomy, two
dophotocoagulation (cases 2, 3, 4, 7,
and 8), one eye underwent removal of a retained metallic foreign body (case
5), and two eyes (cases 4 and 7) under¬ went fluid-gas exchange. There were no intraoperative complications. Visual acuity improved in all eyes following surgery (Table 2). Six eyes demonstrated Snellen acuities ranging between 20/15 and 20/200 during an average postoperative interval of 8 months (range, 3 to 30 months). Two eyes (cases 1 and 5) achieved 20/15 and 20/20 visual acuities. Visual acuity of 20/100
or
less
was
due to diabetic
retinopathy (case 3), macular hole for¬ mation (case 2), or previous macular detachment (case 7). In each case, the
vitreous was clear and the retina at¬ tached. One patient underwent a YAG laser capsulotomy for an opacified pos¬ terior capsule 3 months after surgery (case 2). One patient (case 7) developed an epiretinal membrane and opacified
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posterior capsule and underwent re¬ peated pars plana vitrectomy, mem¬ brane stripping, and excision of the posterior capsule 3 months postoperatively. One patient was successfully fitted with an aphakic soft contact lens 3 months after surgery (case 5). COMMENT
Cataract extraction may be com¬ bined with pars plana vitrectomy if the cataract interferes with visualization of the retina or visual rehabilitation of the patient.' Lensectomy is most com¬ monly performed via the pars plana, and the anterior and posterior lens capsule is usually removed, precluding placement of a posterior chamber lens implant.1 Recently, Blankenship et al2 described a technique of pars plana lensectomy in which the anterior lens capsule and zonules remain intact un¬ til the end of the procedure, allowing insertion of a posterior chamber lens implant in the ciliary sulcus. The dis¬ advantages of this technique include sulcus fixation of the lens implant, technical difficulties of aspirating cor¬ tical material from the anterior cap¬ sule of the lens, and the need for a large central discission in the anterior lens capsule following placement of the in¬ traocular lens. To maintain an intact posterior lens capsule, cataract extraction should be performed using a limbal surgical ap¬ proach. Standard extracapsular sur¬ gery may be performed in conjunction with pars plana vitrectomy.1 However, if it is performed prior to vitrectomy surgery, manipulation of the cornea and prolonged intracameral irrigation may cause corneal edema that inter¬ feres with visualization of the retina. In addition, a large corneoscleral inci¬ sion (10 mm) may leak when the in¬ traocular pressure is elevated during vitrectomy surgery.2 If extracapsular cataract extraction is performed fol¬ lowing vitrectomy, intraoperative vi¬ sualization of the posterior pole may be compromised. In addition, zonular weakness and loss of the vitreous sup¬ port may cause excessive movement of the posterior capsule with a subse¬ quent capsular tear or dehiscence of the zonules, preventing placement of a
posterior chamber lens in the capsular bag.4 These problems may be obviated by combining phacoemulsification with pars plana vitrectomy in eyes with mild to moderate nuclear sclerosis. Phacoemulsification can be performed in the posterior chamber through a 3.2-mm limbal incision without creat¬ ing clinically significant corneal edema. In young individuals with trau¬ matic cataracts, the nucleus can often be aspirated with the phacoemulsifi¬ cation handpiece without using ultra¬ sound energy. Visualization of the pos¬ terior pole remains excellent and does not interfere with subsequent pars
plana vitrectomy rupted
7-0
Temporary single inter¬
surgery.
wound closure with
a
polyglactin
910 suture
minimal corneal distortion and can withstand elevated intraocular pressure that may occur during pars causes
plana vitrectomy. A limbal surgical approach allows the surgeon to maintain the posterior capsule and enables endocapsular fix¬ ation of a posterior chamber lens im¬ plant. In this series, five eyes with pro¬ liferative retinopathy due to diabetes
branch retinal vein occlusion re¬ ceived posterior chamber lenses. Four of these eyes had undergone previous argon laser photocoagulation, and none had preoperative evidence of rubeosis iridis. Due to unilateral aphakia, poor visual potential, and/or di¬ abetic peripheral neuropathy or keratopathy; these patients were believed to be poor candidates for aphakic spec¬ tacle or contact lens correction follow¬ or
ing vitrectomy surgery. Although con¬ troversial, posterior chamber intraoc¬
ular lenses appear to be well tolerated in these patients.45 In eyes with prolif¬ erative diabetic retinopathy, an intact lens capsule may lower the incidence of iris neovascularization and neovas¬ cular glaucoma following cataract ex¬ traction.' In addition, endocapsular fixation sequesters the posterior chamber lens implant from adjacent uveal tissue, reduces pigment disper¬ sion, and helps maintain an intact blood-aqueous barrier.7 Phacoemulsification may not be the preferred technique for cataract ex-
traction in some eyes undergoing com¬ bined lensectomy and vitrectomy. Ul¬ trasonic fragmentation of dense nuclei may require excessive energy and cre¬ ate intraoperative corneal edema. In addition, phacoemulsification is tech¬ nically more difficult to perform in eyes with miotic pupils and may con¬ tribute to intraoperative hemorrhage in eyes with extensive rubeosis iridis. In some eyes with severe proliferative retinopathy, the presence of an intact posterior lens capsule may act as a surface for postoperative fibrin depo¬ sition or fibrovascular proliferation and may contribute to the develop¬ ment of anterior hyaloidal fibrovascu¬ lar proliferation or pupillary block glaucoma.8 Phacoemulsification is contraindicated in eyes with traumatic cataract if there is a mixture of lens and vitreous, a large area of zonular dehiscence, or a large tear in the pos¬ terior capsule. In cases such as these, aspiration of formed vitreous with the
phacoemulsification or irrigation-as¬ piration handpiece may cause exces¬
sive vitreous traction and a retinal tear. Although not contraindicated in the presence of a dense vitreous hem¬ orrhage, loss of the red reflex inter¬ feres with visualization of the lens capsule during anterior capsulotomy and aspiration of residual cortical remnants.
Combining
phacoemulsification
with pars plana vitrectomy is simple and requires little additional instru¬ mentation. Following small-incision cataract extraction through the lim¬ bus, pars plana vitrectomy can be per¬ formed through a clear cornea with a water-tight wound. Maintaining zonu¬ lar and posterior capsule support al¬ lows endocapsular fixation of a poste¬ rior chamber lens implant. By combin¬ ing phacoemulsification and pars plana vitrectomy in selected cases, we can achieve more rapid visual rehabil¬ itation and functional unaided vision
using a single operation. This study was supported in part by an unre¬ stricted grant from Research to Prevent Blind¬ ness Ine, New York, NY, and Core Center Grant EYO 1931 from the National Eye Institute, Be¬ thesda, Md.
References
WE, Blankenship GW, Machemer R. plana lens removal with vitrectomy. Am J Ophthalmol. 1977;84:150. 2. Blankenship GW, Flynn HW, Kokame GT. 1. Benson
Pars
Posterior chamber intraocular lens insertion during pars plana lensectomy and vitrectomy for complications of proliferative diabetic retinopathy. Am J Ophthalmol. 1989;108:1. 3. Kokame GT, Flynn HW, Blankenship GW. Posterior chamber intraocular lens implantation during diabetic pars plana vitrectomy. Ophthal-
mology. 1989;96:603. 4. Smiddy WE, Stark WJ, Michels RG, Maumenee AE, Terry AC, Glaser BM. Cataract extraction after vitrectomy. Ophthalmology. 1987;94:483. 5. Fung WE. Phacoemulsification and implantation of posterior chamber intraocular lens in eyes with quiescent proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol. 1987; 225:251. 6. Poliner LS, Christianson DJ, Escoffery RF, Kolker AE, Gordon ME. Neovascular glaucoma
after intracapsular and extracapsular cataract extraction in diabetic patients. Am J Ophthalmol.
1985;100:637. 7. Apple DJ. Intraocular lenses. Arch Ophthalmol. 1986;104:1150. 8. Lewis H, Abrams GW, Williams GA. Anterior hyaloidal fibrovascular diabetic vitrectomy. Am J 104:607.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 08/19/2013
proliferation after Ophthalmol. 1987;
\s=b\ Combined phacoemulsification and pars plana vitrectomy were performed in eight eyes with cataract and vitreoretinal disease. Six eyes had tractional retinal detachment and/or nonclearing vitreous hemorrhage, one eye had a retained metallic intraocular foreign body, and one eye had a traumatic retinal detachment. In six eyes, a posterior chamber lens implant was placed in the capsular bag. Postoperative visual acuity improved in each case and ranged between 20/15 and 6/200. There were no perioperative complications, and the posterior chamber lens implant appeared well tolerated during an average follow-up interval of 8 months (range, 3 to 30 months). This technique allows endocapsular fixation of a posterior chamber lens and provides rapid visual rehabilitation with a single operation.
(Arch Ophthalmol. 1990;108:362-364)
often removed during Cataractsplana vitrectomy if are
pars
surgery
they interfere with visualization of the posterior pole. Lensectomy is most commonly performed through the pars plana using a vitreous aspiration-cut¬ ting instrument for lenses with soft nuclei or ultrasonic fragmentation for
cataracts with hard nuclei.1 However, pars plana lensectomy requires exci¬
sion of the anterior and/or posterior lens capsule and precludes endocapsu¬ lar fixation of a posterior chamber in¬ traocular lens. We herein describe a surgical technique that combines pha¬ coemulsification and pars plana vitreeAccepted for publication November 14, 1989.
From the Cornea and Vitreoretinal Services of the Eye Institute, The Medical College of Wisconsin, Milwaukee. Reprint requests to Medical College of Wisconsin, Eye Institute, 8700 W Wisconsin Ave, Milwaukee, WI 53226 (Dr Koenig).
a single operation and allows placement of a posterior chamber lens implant in the capsular bag.
tomy in
PATIENTS AND METHODS
We retrospectively reviewed the charts of eight consecutive patients who underwent combined phacoemulsification and pars plana vitrectomy at our institution between December 1986 and June 1989. Preoperative clinical data included the patient's age, sex, type of cataract, underlying vitreous or retinal disease, and preoperative visual acuity. The duration of insulin dependence was noted in patients with diabetes mellitus. Postoperative data included the best corrected visual acuity, follow-up interval,
and results of the fundus examination. The results of the last postoperative examina¬ tion were recorded. One patient (case 3) was unable to return for a follow-up examina¬ tion; postoperative data were provided by the referring ophthalmologist. Preoperatively, pupils were dilated with frequent drops of 5% phenylephrine hydro¬ chloride (Neo-Synephrine), 1% cyclopentolate hydrochloride (Cyclogyl), and 0.03% flurbiprofen sodium (Ocufen), as well as one drop of 0.25% hydrobromide scopolamine. Surgery was performed following the ad¬ ministration of general endotracheal anes¬ thesia (cases 1, 2, 3, 4, 5, 7, and 8) or mon¬ itored local anesthesia (case 6), which in¬ cluded a facial nerve and retrobulbar block using a 1:1 mixture of 2% lidocaine hydro¬ chloride and 0.75% bupivacaine hydrochlo¬ ride with hyaluronidase. All eyes were prepared for pars plana vitrectomy by placing 4-0 black silk sutures transconjunctivally around the rectus mus¬ cles. A 180° fornix-based conjunctival flap was dissected superiorly. Local bleeding was controlled with wet-field cautery. Scle¬ rotomy sites were marked 3.0 to 3.5 mm posterior to the limbus inferotemporally, superonasally, and superotemporally. A su¬ ture was preplaced for the inferotemporal sclerotomy site, and the vitreous cavity was entered with a 19-gauge microvitreal reti¬ nal blade. An infusion cannula (2.5 mm to
4.0
mm)
was
connected to 500 mL of irri¬
gating solution (balanced salt solution en¬
riched with bicarbonate, dextrose, and gluthathione) containing 0.3 mL of 1:1000 epinephrine hydrochloride and secured in place. In eyes receiving a posterior chamber lens implant (cases 1, 2, 3,4, 6, and 8) a 7.0mm partial-depth corneoscleral incision was
made with a razor blade knife 1 to 2 mm
posterior to the superior limbus. A stab in¬
made within the corneoscleral a 3.2-mm keratome. The ante¬ rior chamber was filled with hyaluronate sodium (Healon). A 6-mm-diameter periph¬ eral puncture ("can opener") anterior cap¬ sulotomy was completed with a 25-gauge bent cystotome needle. The phacoemulsifi¬ cation handpiece was introduced into the anterior chamber and the lens nucleus emulsified in the posterior chamber. Resid¬ ual cortical material was aspirated with the 0.3-mm tip of the irrigation-aspiration in¬ strument. The wound was temporarily closed with a single 7-0 polyglactin 910 (Vi-
cision
was
groove with
cryl)
suture.
Two superiorly located sclerotomies were made with a 19-gauge microvitreal retinal blade, and the endoilluminator and vitrec¬ tomy instrument were introduced. After pars plana vitrectomy and adjunctive pro¬ cedures were performed, the light pipe and vitrectomy instrument were removed from the eye and the sclerotomy sites tempo¬ rarily closed with plugs. The retina was then inspected by indirect ophthalmoscopy. The previously placed polyglactin 910 su¬ ture was removed from the cataract wound and the capsular bag filled with Healon. The corneoscleral wound was enlarged to 7 mm using a corneoscleral scissors. A Sinskeystyle posterior chamber lens implant (IOLAB G107G or 108B, IOLAB Corp, Claremont, Calif) was then placed in the capsu¬ lar bag and centered using a Sinskey hook. The pupil was constricted with intracam¬ eral 0.01% carbachol. The corneoscleral wound was then closed with multiple inter¬ rupted 10-0 monofilament nylon sutures. Prior to completion of the wound closure, residual Healon was removed from the an-
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terior chamber with the 0.3-mm tip of the irrigation-aspiration instrument. Fluidgas exchange was performed in two eyes after extracapsular cataract extraction (case 7) and posterior chamber intraocular lens insertion (case 4). The sclerotomy plugs were removed, and the sites closed with interrupted 7-0 polyglycolic acid (Dexon) sutures. The conjunctival flap was reapproximated with interrupted 7-0 poly¬ glycolic acid sutures. Subconjunctival gentamicin sulfate (20 mg) and dexamethasone sodium phosphate (12 mg) were adminis¬ tered. The eye was treated with topical 1% atropine sulfate and gentamicin ointment prior to patching. Postoperatively, eyes were treated with topical 0.25% scopola¬ mine, 0.3% gentamicin, and 1% prednisolone phosphate. Postoperative visual acuities were mea¬ sured using a soft contact lens (case 5), spectacles (case 1), or a pinhole correction. Postoperative maculopathy was diagnosed by slit-lamp biomicroscopy and a 90-diopter lens or indirect ophthalmoscopy. RESULTS
Six
and two (Table 1). The average age at the time of surgery was 56 years (range, 26 to 74 years). Six eyes had dense vitreous hemorrhages that failed to clear during a period of at least 6 months. Four of these six eyes had long-standing insulin-dependent diabetes mellitus with proliferative retinopathy and had undergone previ¬ ous panretinal or focal argon laser photocoagulation. Two eyes had dia¬ betic tractional retinal detachment (cases 3 and 4). One eye (case 2) had developed neovascularization and vit¬ reous hemorrhage following a branch retinal vein occlusion. None of the eyes in this series exhibited iris neovascu¬ larization. One eye (case 5) had a small retained intravitreal metallic foreign body. One patient (case 7), with a psy¬ chiatric disorder, developed a total rhegmatogenous retinal detachment following self-inflicted blunt ocular
patients
were women
were men
trauma. All eyes in this series had cataracts. Four eyes had immature senile cata¬ racts with mild to moderate nuclear sclerosis (cases 1, 2, 3, and 6), and two eyes (cases 4 and 8) had predominantly
posterior subcapsular or anterior cor¬ tical cataracts. One eye (case 5) devel¬ oped a rosette-shaped posterior sub¬ capsular cataract with anterior corti¬ cal spokes following perforation of the lens with a metallic foreign body. One eye (case 7) had a mature cortical cat¬ aract after blunt trauma. In each case,
the
hazy media (cataract and vitreous hemorrhage) were significant in limit¬ ing visual acuity. Preoperative visual acuity ranged between light percep¬ tion and 20/400.
Table Patient No./
1.—Preoperative Clinical Information*
Vitreoretinal Disease
Age, y/Sex 1/67/M
PDR OS; vitreous heme (7 mo), status post focal argon laser Branch retinal vein
2/70/F
Vision
Cataract
Comments IDDM (30
NS; +2 corti¬ cal; + 1 PSC
y); peripheral neuropathy
+2
+ 3-4
NS; +1 PSC
Possible macular
LP
occlusion OD; vitreous heme
hole
(24 mo) 3/73/F
PDR OD; vitreous
mo); post PRP
heme (9 status
+2
HM at 5 tt
cortical;
IDDM
(20 y)
+ 1 NS IDDM (17
4/35/F
PDR OD; vitreous heme (6 mo);
5/30/M
Retained intraocu¬ lar foreign body
6/74/F
PDR; vitreous heme (6 mo); status post PRP_
7/26/F
Traumatic retinal detachment
+4 cortical
LP
Macula detached
8/69/F
PDR; vitreous heme (6 mo)
+2 PSC
20/200
IDDM
status _
post
+2 cortical; +1 PSC
PRP_
OD
y)
CF at 5 ft
Traumatic with small posterior capsular tear
IDDM
+2 NS; + 1 cortical; + 1 PSC
(22 y)
(6 y)
*PDR indicates proliferative diabetic retinopathy; NS, nuclear sclerosis; IDDM, insulin-dependent diabetes mellltus; PSC, posterior subcapsular; LP, light perception; HM, hand motions; PRP, panretinal photocoagulation; and CF, counting fingers.
Table Patient No.
2.—Postoperative Clinical Information Follow-up,
Visual Retina
Acuity 6/200
Comments
mo
30
20/15
YAG laser
Macular hole
3
20/400 20/50
mo
capsulotomy postoperatively
Diabetic macular edema Diabetic macular edema
Aphakic
soft contact lens correction
20/50
Diabetic macular edema
20/200
Macular
Vitrectomy, macular eplretlnal membrane stripping, capsulectomy
pigmentary
abnormalities 20/40
Diabetic macular edema
Six eyes underwent combined pha¬ pars plana vitrecto¬ my, and insertion of a posterior cham¬ ber intraocular lens (cases 1, 2, 3, 4, 6, and 8). Due to the possibility of post¬
coemulsification,
operative endophthalmitis (case 5) or recurrent retinal detachment (case 7), two eyes did not receive lens implants. Following phacoemulsification, all cor¬ neas remained clear; however, during pars plana vitrectomy, one eye (case 5) developed exposure keratopathy and required epithelial débridement for adequate visualization of the posterior pole. In addition to pars plana vitrec¬ eyes underwent retinal membrane stripping (cases 3 and 4), five eyes underwent argon laser en-
tomy, two
dophotocoagulation (cases 2, 3, 4, 7,
and 8), one eye underwent removal of a retained metallic foreign body (case
5), and two eyes (cases 4 and 7) under¬ went fluid-gas exchange. There were no intraoperative complications. Visual acuity improved in all eyes following surgery (Table 2). Six eyes demonstrated Snellen acuities ranging between 20/15 and 20/200 during an average postoperative interval of 8 months (range, 3 to 30 months). Two eyes (cases 1 and 5) achieved 20/15 and 20/20 visual acuities. Visual acuity of 20/100
or
less
was
due to diabetic
retinopathy (case 3), macular hole for¬ mation (case 2), or previous macular detachment (case 7). In each case, the
vitreous was clear and the retina at¬ tached. One patient underwent a YAG laser capsulotomy for an opacified pos¬ terior capsule 3 months after surgery (case 2). One patient (case 7) developed an epiretinal membrane and opacified
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posterior capsule and underwent re¬ peated pars plana vitrectomy, mem¬ brane stripping, and excision of the posterior capsule 3 months postoperatively. One patient was successfully fitted with an aphakic soft contact lens 3 months after surgery (case 5). COMMENT
Cataract extraction may be com¬ bined with pars plana vitrectomy if the cataract interferes with visualization of the retina or visual rehabilitation of the patient.' Lensectomy is most com¬ monly performed via the pars plana, and the anterior and posterior lens capsule is usually removed, precluding placement of a posterior chamber lens implant.1 Recently, Blankenship et al2 described a technique of pars plana lensectomy in which the anterior lens capsule and zonules remain intact un¬ til the end of the procedure, allowing insertion of a posterior chamber lens implant in the ciliary sulcus. The dis¬ advantages of this technique include sulcus fixation of the lens implant, technical difficulties of aspirating cor¬ tical material from the anterior cap¬ sule of the lens, and the need for a large central discission in the anterior lens capsule following placement of the in¬ traocular lens. To maintain an intact posterior lens capsule, cataract extraction should be performed using a limbal surgical ap¬ proach. Standard extracapsular sur¬ gery may be performed in conjunction with pars plana vitrectomy.1 However, if it is performed prior to vitrectomy surgery, manipulation of the cornea and prolonged intracameral irrigation may cause corneal edema that inter¬ feres with visualization of the retina. In addition, a large corneoscleral inci¬ sion (10 mm) may leak when the in¬ traocular pressure is elevated during vitrectomy surgery.2 If extracapsular cataract extraction is performed fol¬ lowing vitrectomy, intraoperative vi¬ sualization of the posterior pole may be compromised. In addition, zonular weakness and loss of the vitreous sup¬ port may cause excessive movement of the posterior capsule with a subse¬ quent capsular tear or dehiscence of the zonules, preventing placement of a
posterior chamber lens in the capsular bag.4 These problems may be obviated by combining phacoemulsification with pars plana vitrectomy in eyes with mild to moderate nuclear sclerosis. Phacoemulsification can be performed in the posterior chamber through a 3.2-mm limbal incision without creat¬ ing clinically significant corneal edema. In young individuals with trau¬ matic cataracts, the nucleus can often be aspirated with the phacoemulsifi¬ cation handpiece without using ultra¬ sound energy. Visualization of the pos¬ terior pole remains excellent and does not interfere with subsequent pars
plana vitrectomy rupted
7-0
Temporary single inter¬
surgery.
wound closure with
a
polyglactin
910 suture
minimal corneal distortion and can withstand elevated intraocular pressure that may occur during pars causes
plana vitrectomy. A limbal surgical approach allows the surgeon to maintain the posterior capsule and enables endocapsular fix¬ ation of a posterior chamber lens im¬ plant. In this series, five eyes with pro¬ liferative retinopathy due to diabetes
branch retinal vein occlusion re¬ ceived posterior chamber lenses. Four of these eyes had undergone previous argon laser photocoagulation, and none had preoperative evidence of rubeosis iridis. Due to unilateral aphakia, poor visual potential, and/or di¬ abetic peripheral neuropathy or keratopathy; these patients were believed to be poor candidates for aphakic spec¬ tacle or contact lens correction follow¬ or
ing vitrectomy surgery. Although con¬ troversial, posterior chamber intraoc¬
ular lenses appear to be well tolerated in these patients.45 In eyes with prolif¬ erative diabetic retinopathy, an intact lens capsule may lower the incidence of iris neovascularization and neovas¬ cular glaucoma following cataract ex¬ traction.' In addition, endocapsular fixation sequesters the posterior chamber lens implant from adjacent uveal tissue, reduces pigment disper¬ sion, and helps maintain an intact blood-aqueous barrier.7 Phacoemulsification may not be the preferred technique for cataract ex-
traction in some eyes undergoing com¬ bined lensectomy and vitrectomy. Ul¬ trasonic fragmentation of dense nuclei may require excessive energy and cre¬ ate intraoperative corneal edema. In addition, phacoemulsification is tech¬ nically more difficult to perform in eyes with miotic pupils and may con¬ tribute to intraoperative hemorrhage in eyes with extensive rubeosis iridis. In some eyes with severe proliferative retinopathy, the presence of an intact posterior lens capsule may act as a surface for postoperative fibrin depo¬ sition or fibrovascular proliferation and may contribute to the develop¬ ment of anterior hyaloidal fibrovascu¬ lar proliferation or pupillary block glaucoma.8 Phacoemulsification is contraindicated in eyes with traumatic cataract if there is a mixture of lens and vitreous, a large area of zonular dehiscence, or a large tear in the pos¬ terior capsule. In cases such as these, aspiration of formed vitreous with the
phacoemulsification or irrigation-as¬ piration handpiece may cause exces¬
sive vitreous traction and a retinal tear. Although not contraindicated in the presence of a dense vitreous hem¬ orrhage, loss of the red reflex inter¬ feres with visualization of the lens capsule during anterior capsulotomy and aspiration of residual cortical remnants.
Combining
phacoemulsification
with pars plana vitrectomy is simple and requires little additional instru¬ mentation. Following small-incision cataract extraction through the lim¬ bus, pars plana vitrectomy can be per¬ formed through a clear cornea with a water-tight wound. Maintaining zonu¬ lar and posterior capsule support al¬ lows endocapsular fixation of a poste¬ rior chamber lens implant. By combin¬ ing phacoemulsification and pars plana vitrectomy in selected cases, we can achieve more rapid visual rehabil¬ itation and functional unaided vision
using a single operation. This study was supported in part by an unre¬ stricted grant from Research to Prevent Blind¬ ness Ine, New York, NY, and Core Center Grant EYO 1931 from the National Eye Institute, Be¬ thesda, Md.
References
WE, Blankenship GW, Machemer R. plana lens removal with vitrectomy. Am J Ophthalmol. 1977;84:150. 2. Blankenship GW, Flynn HW, Kokame GT. 1. Benson
Pars
Posterior chamber intraocular lens insertion during pars plana lensectomy and vitrectomy for complications of proliferative diabetic retinopathy. Am J Ophthalmol. 1989;108:1. 3. Kokame GT, Flynn HW, Blankenship GW. Posterior chamber intraocular lens implantation during diabetic pars plana vitrectomy. Ophthal-
mology. 1989;96:603. 4. Smiddy WE, Stark WJ, Michels RG, Maumenee AE, Terry AC, Glaser BM. Cataract extraction after vitrectomy. Ophthalmology. 1987;94:483. 5. Fung WE. Phacoemulsification and implantation of posterior chamber intraocular lens in eyes with quiescent proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol. 1987; 225:251. 6. Poliner LS, Christianson DJ, Escoffery RF, Kolker AE, Gordon ME. Neovascular glaucoma
after intracapsular and extracapsular cataract extraction in diabetic patients. Am J Ophthalmol.
1985;100:637. 7. Apple DJ. Intraocular lenses. Arch Ophthalmol. 1986;104:1150. 8. Lewis H, Abrams GW, Williams GA. Anterior hyaloidal fibrovascular diabetic vitrectomy. Am J 104:607.
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proliferation after Ophthalmol. 1987;
