Combined Phacoemulsification, Pars Plana Vitrectomy, and Posterior Chamber Intraocular Lens Insertion Steven B. Koenig, MD; William F. Mieler, MD; Dennis P. Han, MD;

\s=b\ Eighteen eyes with coexisting cataract and vitreoretinal disease underwent combined phacoemulsification, pars plana vitrectomy, and posterior chamber lens implantation. Preoperative vitreoretinal disease included nonclearing vitreous hemorrhage (eight eyes), vitreous hemorrhage and tractional retinal detachment (three eyes), tractional retinal detachment (one eye), epiretinal membranes

(three eyes), peripheral uveitis (two eyes), and a retained intraocular metallic foreign body (one eye). Postoperative visual acuity improved in each case; 14 eyes achieved visual acuity between 20/20 and 20/80 during an average postoperative period of 11 months (range, 3 to 39 months). Perioperative complications included an iatrogenic retinal break (one eye) and pupillary block glaucoma (one eye). Four eyes required YAG laser capsulotomy postoperatively. Phacoemulsification did not interfere with corneal clarity, allowed water-tight wound closure during vitrectomy, and preserved the capsular bag, allowing endocapsular fixation of the posterior chamber lens. Combining phacoemulsification, posterior chamber lens implantation, and pars plana vitrectomy allows rapid visual rehabilitation and functional unaided vision in these eyes. {Arch Ophthalmol. 1992 ;110:1101 -1104)

/Cataract extraction may be combined ^ with pars plana vitrectomy if the cataract interferes with the surgeon's view of the retina or with the visual re¬ habilitation of the patient. Lensectomy is most frequently performed through the pars plana using a vitreous aspira¬ tion cutting instrument or an ultrasonic fragmentation needle.1 Pars plana lensectomy usually requires excision of the anterior and posterior lens capsule, precluding placement of a posterior chamber intraocular lens. Despite excel¬ lent anatomic results, visual rehabilita-

Accepted for publication February 25, 1992. From the Department of Ophthalmology, Medical College of Wisconsin, Milwaukee. Reprint requests to Eye Institute, 8700 W Wisconsin Ave, Milwaukee, WI 53226 (Dr Koenig).

Gary W. Abrams,

MD

tion of these eyes is often complicated since many patients are either unable or

unwilling

to

wear an

aphakic

contact

lens. Posterior chamber lens implanta¬ tion may accompany pars plana lensec¬ tomy if the anterior lens capsule re¬ mains in place.2·3 However, this tech¬ nique requires sulcus fixation of the lens implant and a large central discission of the anterior lens capsule, which may in¬ crease the risk of neovascular glaucoma in high-risk eyes.4 To avoid these prob¬ lems, we have combined phacoemulsifi¬ cation with pars plana vitrectomy.5 This surgical technique is simple, does not in¬ terfere with the vitrectomy surgery, and allows endocapsular fixation of a posterior chamber lens. PATIENTS AND METHODS We retrospectively reviewed the medical records of 18 consecutive patients who un¬ derwent combined phacoemulsification and pars plana vitrectomy at our institution be¬ tween December 1986 and December 1990. During this period, no patients underwent combined pars plana vitrectomy and phacoe¬ mulsification without intraocular lens im¬ plantation. Preoperative information in¬ cluded the patient's age, sex, cataract type, underlying vitreoretinal disease, and preop¬ erative visual acuity. The duration of insulin dependence was noted in patients with dia¬ betes mellitus. Postoperative information included the best-corrected visual acuity, follow-up interval, and results of the fundus examination. The results of the last postop¬ erative examination were recorded. One pa¬ tient (case 3) was unable to return for a follow-up examination; postoperative data were provided by the referring ophthalmol¬

ogist. Preoperatively, pupils were dilated with drops of 5% phenylephrine hydrochloride (Neo-Synephrine), 1% cyclopentolate hydrochloride (Cyclogyl), and 0.03% flurbiprofen sodium (Ocufen), as well as 0.25% hydrobromide scopolamine. Surgery was performed following the administration of general endotracheal anesthesia or monitored local an¬ esthesia (case 5), which included a facial nerve and retrobulbar block using a 1:1 mix¬ ture of 2% lidocaine hydrochloride and 0.75% bupivacaine hydrochloride with hyaluronidase. All eyes were prepared for a three-port

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pars plana vitrectomy by placing 4-0 black silk sutures transconjunctivally around the rectus muscles. A 180° fornix-based conjunc¬ tival flap was dissected superiorly. Local bleeding was controlled with wet-field cau¬ tery. Sclerotomy sites were marked 3.0 mm posterior to the limbus inferotemporally, superonasally, and superotemporally. A suture was preplaced for the inferotemporal sclerot¬ omy site, and the vitreous cavity was en¬ tered with a 19-gauge microvitreal retinal blade. The infusion cannula (2.5 to 4 mm) was connected to a 500-mL bottle of irrigating solution (balanced salt solution enriched with bicarbonate, dextrose, and glutathione, Alcon Laboratories Ine, Fort Worth, Tex) con¬ taining 0.3 mL of 1:1000 epinephrine hydro¬ chloride and secured in place. A 6.5- to 7.0-mm partial-depth corneoscleral incision was made with a razor blade knife 1 to 2 mm posterior to the superior limbus. A stab incision was made within the corneoscleral groove with a 3.0- or 3.2-mm keratome. The anterior chamber was filled with hyaluronate sodium (Healon, Pharma¬ cia Ine, Piscataway, NJ). A 6-mm-diameter peripheral puncture ("can opener") anterior capsulotomy was made with a 25-gauge bent cystotome needle. The phacoemulsification needle (45° or 60° tip) was introduced into the anterior chamber and the lens nucleus emul¬ sified in the posterior chamber. Residual 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-

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 proce¬ dures were performed, the light pipe and vitrectomy instrument were removed from the eye and the sclerotomy sites temporarily closed with plugs. The retina was then in¬ spected by indirect ophthalmoscopy. If the retina was anatomically stable, the previ¬ ously placed polyglactin 910 suture was re¬ moved from the cataract wound and the cap¬ sular bag filled with hyaluronate. The corneoscleral wound was enlarged to 6.5 to 7 mm using a corneoscleral scissors. A Sinskey-style posterior chamber lens im¬ plant (IOLAB G107B or 108B, IOLAB Corp, Claremont, Calif) was then placed in the capsular bag and centered with a Sinskey hook (Storz Instrument Co, St Louis, Mo). The pupil was constricted with intracameral

Table

No./Age, y/Sex

1.—Preoperative Clinical Data*

Patient

Vitreoretinal Disease

Comments

1/67/M 2/70/F 3/73/F

PDR, OS; vitreous heme BRVO, OD; vitreous heme PDR, OD; fractional RD;

Cataract +2 NS; +2 cortical; +1 PSC +3-4 NS; +1 PSC +2 cortical; +1 NS

Vision HM at 2 ft LP HM at 5 ft

IDDM (30 y) Macular hole IDDM (20 y)

4/35/F

PDR, OD; tractional RD;

+2 cortical; +1 PSC

20/400

IDDM

(17 y)

5/74/F 6/69/F 7/67/M 8/28/M

vitreous heme PDR, OD; vitreous heme PDR, OD; vitreous heme PDR, OS; vitreous heme Retained metallic Intraocular

+2 NS; +1 cortical; +1 PSC +2 PSC +2 NS; +2 PSC

IDDM IDDM IDDM

Traumatic

20/400 20/200 20/200 5/200

(22 y) (6 y) (10 y)

+1 NS; +2-3 PSC +1 NS; +1 PSC +3 PSC +2 NS; +2 PSC +2 NS; +2-3 PSC +3-4 NS; +2 PSC +3 NS

20/200 HM 20/70 CF at 2 ft 20/400 HM 6/200

IDDM IDDM

(8 y) (26 y)

IDDM (10 y) IDDM (8 y) Rubeosis irldis; COAG (3 y) s/p PPV+SB for rhegmatogenous RD

+1 NS; +2 PSC +3 PSC

20/70 20/300

s/p SB

+2 NS; +1 cortical; +1 PSC

20/50

vitreous heme

foreign body 9/71/M 10/31/M 11/34/F 12/69/M 13/47/F 14/80/M 15/72/F

PDR, OD; tractional RD; vitreous heme PDR, OD; vitreous heme Pars

planitls,

OD

PDR, OS; vitreous heme PDR, OS; tractional RD CRVO, OD; vitreous heme PVR with epiretinal membrane, OS Pars planitls, OD PVR with epiretinal membrane, OS Idlopathic epiretinal membrane

16/42/F 17/30/M 18/81/M

x3 for

rhegmatogenous

RD

*PDR Indicates proliferative diabetic retinopathy; NS, nuclear sclerosis; PSC, posterior subcapsular cataract; HM, hand motions; IDDM, Insulin-dependent di¬ abetes mellitus; BRVO, branch retinal vein occlusion; LP, light perception; RD, retinal detachment; CF, counting fingers; CRVO, central retinal vein occlusion; COAG, chronic open angle glaucoma; PVR, proliferative vitreoretinopathy; s/p, status post; PPV, pars plana vitrectomy; and SB, scierai buckle.

0.01% carbachol, unless further posterior vi¬ sualization was required. The corneoscleral wound was then closed with multiple inter¬ rupted 10-0 monofilament nylon sutures. Before completion of the wound closure, the residual hyaluronate was removed from the anterior chamber with the 0.3-mm tip of the irrigation-aspiration instrument. Fluid-gas exchange was performed in three eyes (cases 4,9, and 10) after posterior chamber intraoc¬ ular lens insertion. The sclerotomy plugs were removed, and the sites closed with in¬ terrupted 7-0 polyglycolic acid (Dexan) su¬ tures. The conjunctival flap was reapproximated with interrupted 7-0 polyglycolic acid sutures. Subconjunctival gentamicin sulfate (20 mg) and dexamethasone sodium phos¬ phate (12 mg) were administered. The eye was treated with topical 1% atropine sulfate and gentamicin ointment before patching. Postoperatively, eyes were treated with top¬ ical 0.25% scopolamine hydrochloride, 0.3% gentamicin, and 1% prednisolone phosphate. Postoperative visual acuities were mea¬ sured using spectacles or a pinhole correc¬ tion. Postoperative maculopathy was diag¬ nosed by slit-lamp biomicroscopy and 90diopter lens or indirect ophthalmoscopy.

RESULTS

Nine of the 18 were men

patients in this study

(Table 1). The average age at

the time of surgery was 58 years (range, 28 to 81 years). Preoperative visual acuity ranged between light perception and 20/50. All eyes in this series had clinically significant cataracts that were thought to interfere with visualization of the retina preoperatively. Eight eyes had immature senile cataracts with com¬ bined nuclear sclerosis and posterior subcapsular opacification. Three eyes

had

predominantly nuclear sclerotic opacification. Three of the eyes (cases 2, 14, and 15) with nuclear sclerosis

were

thought to have dense nuclei preoperatively. In one eye (case 8), a traumatic cataract developed following perfora¬ tion with a metallic intraocular foreign body. Eight eyes with vitreous hemorrhage

and three eyes with vitreous hemor¬ rhage and tractional retinal detachment failed to clear during a period of at least 6 months. Nine of these 11 eyes were in patients who had long-standing insulindependent diabetes mellitus with pro¬ liferative diabetic retinopathy and had undergone previous panretinal or focal argon laser photocoagulation, while two eyes had vitreous hemorrhages associ¬ ated with a branch retinal vein occlusion (case 2) or a central retinal vein occlu¬ sion (case 14). One eye (case 13) had a diabetic tractional detachment only; two (cases 15 and 17) had epiretinal membranes secondary to proliferative vitreoretinopathy that had been previ¬ ously treated and considered stable; one (case 18) had an idiopathic epiretinal membrane; two (cases 11 and 16) had peripheral uveitis; and one eye (case 8) had a retained intraretinal metallic for¬ eign body. One patient with a central retinal vein occlusion (case 14) exhib¬ ited rubeosis iridis preoperatively. In this series, all corneas remained clear during phacoemulsification and pars plana vitrectomy, and throughout the postoperative period. Adjunctive vitreoretinal surgery included argon laser endophotocoagulation (cases 2

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through 7, 9, 12, and 14), retinal mem¬ brane stripping (cases 3, 4, 7,12,13,15, 17, and 18), air-fluid exchange (cases 4, 9, and 10), peripheral cryopexy (case 16), and removal of a retinal metallic in¬ traocular foreign body (case 8). One pa¬ tient (case 4) experienced an iatrogenic retinal break during surgery, which was treated with endolaser. No compli¬

cations were related to the cataract ex¬ the posterior capsule re¬ mained intact in each case. The postoperative visual acuity im¬ proved in each case (Table 2). Four¬ teen (78%) of 18 eyes demonstrated Snellen visual acuities ranging be¬ tween 20/20 and 20/80 during an aver¬ age postoperative period of 11 months (range, 3 to 39 months). Seven of these eyes (cases 1, 4, 6, 11, 13, 16, and 18) demonstrated 20/40 or better visual acuity. Of the remaining four eyes with 20/200 or worse visual acu¬ ity, the decreased vision was attrib¬ uted to diabetic macular edema (case 3), macular hole formation (case 2), retinal ischemia secondary to a cen¬ tral retinal vein occlusion (case 14), or retinal pigment epithelial rarefaction associated with a previous rheg¬ matogenous retinal detachment (case 15). One patient (case 10) suffered a mild recurrent vitreous hemorrhage and underwent additional argon laser photocoagulation. In all cases, the ret¬ ina remained attached throughout the

traction;

postoperative period. In one patient (case 13) with postop¬ erative fibrinous iritis, pupillary block developed that was successfully treated

Table Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Visual Acuity 20/20 6/200 20/400 20/40 20/50 20/40 20/50 20/70 20/80 20/70 20/25 20/60 20/20

CF at 1 ft 20/400 20/20 20/60 20/30

*PC Indicates posterior capsule; CF, counting

2.—Postoperative Clinical

Follow-up,

Retina

Macular hole Diabetic macular edema Diabetic macular edema Diabetic macular edema Diabetic macular edema Diabetic macular edema Branch retinal artery occlusion Stable Diabetic macular edema Stable Diabetic macular edema Stable Retinal Ischemia RPE rarefaction Stable Stable Stable

fingers;

with a YAG laser iridotomy. One pa¬ tient with preoperative rubeosis iridis (case 14) suffered neovascular glaucoma postoperatively. In four eyes (cases 2,8, 11, and 18), clinically significant opacifl¬ cation of the posterior capsule devel¬ oped that required YAG laser capsul¬ otomy. None of the patients requiring YAG laser capsulotomy had prolifera¬ tive diabetic retinopathy. COMMENT

Cataract extraction is usually com¬ bined with pars plana vitrectomy in eyes with coexisting vitreoretinal dis¬ ease and clinically significant cataract. The most widely performed technique includes combining pars plana lensec¬ tomy with vitrectomy.1 Traditionally, pars plana lensectomy required exci¬ sion of the anterior and posterior cap¬ sule of the lens, precluding placement of a posterior chamber lens implant and increasing the risk of postvitrectomy neovascular glaucoma in high-risk eyes.6 Although combined pars plana lensectomy and vitrectomy may achieve anatomically successful results, the visual rehabilitation of these aphakic eyes is often problematic. Patients with unilateral aphakia and reduced vi¬ sual potential may not be motivated to wear a contact lens postoperatively. In addition, patients with long-standing insulin-dependent diabetes mellitus and peripheral polyneuropathy may be un¬ able to handle contact lenses or may be at increased risk of contact lensinduced corneal abrasions.7 Finally, aphakic spectacle correction causes con¬ striction of the visual field and optical distortion and is poorly tolerated in eyes with macular disease.8 Extracapsular cataract extraction and posterior chamber lens implanta¬ tion appear to be well tolerated in eyes following pars plana vitree-

and RPE, retinal

tomy.!l'10

Data* Comments Stable retinopathy YAG capsulotomy 3 mo postoperatively

mo

39 6 13 16 4 4 6 8

YAG capsulotomy 8 mo postoperatively Moderate PC opaciflcation Mild PC opaciflcation YAG capsulotomy 11 mo postoperatively

4

11 11 3 14 8 6 11 16 20

Pupillary block; YAG ¡ridotomy Neovascular glaucoma Mild PC opaciflcation YAG

capsulotomy

14

mo

postoperatively

pigment epithelium.

Standard

extracapsular cata¬ posterior chamber

ract extraction and

lens implantation have been combined with pars plana vitrectomy.2 How¬ ever, if cataract extraction is per¬ formed before the vitrectomy, corneal manipulation and prolonged irrigation of the corneal endothelium with bal¬ anced salt solution may lead to intra¬ operative corneal edema and obscure the surgeon's view of the retina. In addition, the large corneoscleral wound required to deliver the lens nucleus may leak if the intraocular pressure is elevated during vitrec¬ tomy surgery. If extracapsular cata¬ ract extraction is delayed until after pars plana vitrectomy, the view of the retina may be compromised by the cataract during the vitrectomy proce¬ dure. Following vitrectomy, the ab¬ sence of vitreous support for the pos¬ terior capsule may complicate expression of the nucleus and cause excessive capsule movement during cortical aspiration, increasing the risk of an inadvertent posterior capsular tear.9 Finally, placement of the poste¬ rior chamber lens implant before com¬ pletion of the vitrectomy may cause anterior chamber pigment dispersion and annoying light reflexes that may interfere with visualization of the pos¬ terior pole.3 To avoid some of these problems, Blankenship et al3 described a tech¬ nique of combined lensectomy and vit¬ rectomy similar to that of Girard,11 in which a posterior chamber lens is placed at the end of the surgery. This tech¬ nique employs two 19-gauge needles inserted through the pars plana to si¬ multaneously infuse and aspirate the cataractous lens. During the subse¬ quent pars plana vitrectomy, the resid¬ ual posterior lens capsule is excised, leaving the anterior capsule and zonules

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intact. After the vitrectomy, a posterior chamber lens is inserted through a limbal wound into the ciliary sulcus ante¬ rior to the anterior lens capsule. Fol¬ lowing wound closure, the vitrectomy instrument is then used to create a large central discission in the anterior lens

capsule. The advantages

of the Blankenship combined technique are that lensec¬ tomy is performed through the pars plana without inducing corneal distor¬ tion that may interfere with the vit¬ rectomy portion of the procedure. It also allows the surgeon to complete the lensectomy and vitrectomy and to inspect the retina before inserting the posterior chamber lens.3 However, the disadvantages include sulcus fixa¬ tion of the posterior chamber lens, the large discission in the residual an¬ terior lens capsule, and potential diffi¬ culties of aspirating residual cortical debris from the posterior surface of the anterior capsule. In addition, re¬ moval of lenses with moderately dense nuclear sclerosis may be diffi¬ cult to perform, even using ultrasonic

fragmentation.

these remaining prob¬ have employed a technique that combines phacoemulsification with pars plana vitrectomy.5·12 Phacoemulsi¬ fication allows cataract extraction to be performed on lenses of varying density through a small (3.0 to 3.2 mm) limbal incision that minimizes corneal distor¬ tion and manipulation. The small wound also allows temporary water-tight wound closure during the vitrectomy portion of the operation. Most impor¬ tantly, the limbal surgical approach al¬ lows the posterior capsule to remain in¬ tact and enables endocapsular fixation of a posterior chamber lens. Mainte¬ nance of the posterior capsule may reduce the incidence of neovascular To

lems,

overcome we

glaucoma in high-risk eyes with venous occlusion or proliferative diabetic retin¬ opathy.4 However, in our study, one pa¬

tient with branch retinal vein occlusion underwent YAG laser capsulotomy, and two patients with proliferative dia¬ betic retinopathy suffered mild to mod¬ erate opaciflcation of the posterior cap¬ sule and may require YAG laser capsulotomy in the future. With contin¬ ued follow-up, it is possible that clini¬

cally significant posterior capsular opacification will develop in additional eyes and may require YAG laser cap¬ sulotomy. It is unknown whether pre¬ vious argon laser photocoagulation will fully inhibit the formation of rubeosis iridis and neovascular glaucoma in these eyes. Endocapsular fixation of the lens implant enhances centration of the intraocular lens and reduces pigment dispersion created by the mechanical chafing of the haptics against the pos¬ terior pigment epithelium of the iris.

Our results indicate that excellent functional visual acuity may be attained by combining pars plana vitrectomy with phacoemulsification and posterior chamber intraocular lens implantation in eyes with a variety of coexisting vitreoretinal diseases and cataracts. In each case, the cornea remained clear and the retina was attached during an average follow-up period of 11 months (range, 3 to 39 months). Visual acuity improved in each case: 38% demon¬ strated 20/40 or better visual acuity and 78% achieved 20/80 or better visual acuity following surgery. Poor postop¬ erative visual acuity (