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| EDITORIAL COMMENTARY |
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| Year : 2019 | Volume
: 12
| Issue : 2 | Page : 71-72 |
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Vitrectomy versus Phaco-vitrectomy
Ahmed Sulaiman Al-Hinai
Department of Ophthalmology, Vitreoretinal Unit, Sultan Qaboos University Hospital, Muscat, Oman
| Date of Web Publication | 4-Jun-2019 |
Correspondence Address:
Dr. Ahmed Sulaiman Al-Hinai
Senior Consultant, Department of Ophthalmology, Vitreoretinal Unit, Sultan Qaboos University Hospital, Muscat
Oman
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.OJO_105_2019
How to cite this article:
Al-Hinai AS. Vitrectomy versus Phaco-vitrectomy. Oman J Ophthalmol 2019;12:71-2 |
Pars plana vitrectomy (PPV) procedure is a closed-system intraocular operation. It is considered to be an eminent step in the evolution of vitreoretinal surgery. It was introduced in 1971 by Norton and Machemer.[1] Since then, PPV had advanced tremendously in various aspects, especially in port's size and cut rate. Smaller gauge PPV (25G and 27G) is currently used to treat various vitreoretinal conditions.
PPV is indicated to treat different vitreoretinal conditions such as retinal detachment, dropped crystalline lens materials, vitreous hemorrhage, and endophthalmitis. However, vitreoretinal conditions are often present with simultaneous cataract. On the other hand, PPV is a procedure which is dependent on detailed visualization of the surgical field and depth of focus, and therefore, the clarity of the ocular media is an essential requirement for complete and successful vitreoretinal surgery. Hence, combined PPV with cataract extraction is a widely accepted approach. In fact, the recent technical advances in instrumentations and small incision approach for both cataract surgery and vitrectomy make it easier to combine both surgeries.
Cataract surgery, when it is combined with PPV, includes either phacoemulsification or extracapsular cataract extraction. During the combined procedure, the cataract surgery is usually performed before PPV. The decision for combined approach is easy when the cataract is visually significant. Hence, this will be an advantage to both, the patient and the surgeon. The dilemma comes up when the cataract is mild or even nonexistent. Some surgeons will proceed with PPV only, and the cataract extraction is left for another sequential surgery if needed. Others will still go ahead with the combined surgery.
Preservation of the crystalline lens when performing PPV has some benefits. This is true especially in pediatric population when accommodation function of the crystalline lens is crucial in this age group. The accommodation is very crucial during the visual development of a child. It also provides an important aid to perform daily activities in older children. Incidence of post-PPV cataract in children is not low since cataract can develop in 15% of pediatric eyes after PPV.[2] On the other hand, lensectomy during PPV is sometimes important in selected pediatric group such in eyes with concomitant cataract and/or ectopic lenses. In some cases, in which manipulation of peripheral retina is required, lens extraction is a preferred tactic to provide more space and avoid the risk of lens touch during PPV.
Performing PPV alone in phakic older age patients is a gray zone. Decision for lens extraction should be revived by the operating surgeons before proceeding to PPV. It is also a challenge to some vitreoretinal surgeons who are not expert in cataract surgeries. Lens accommodation, as mentioned earlier, is lost when the lens is extracted, and that is more obvious in younger patients, who are less than 40 years of age. Some anterior segment adverse events such as corneal decompensation and inflammatory reaction are also more possible to occur after the combined surgery, but usually, they are transient.
Flipping the coin to the other side will open the discussion further. Certainly, multiple surgeries on the same eye add an extra stress for that eye. Combined surgery of cataract extraction and PPV has many advantages over PPV alone on phakic eyes. These advantages are clinical, economical, and even social. A vitreoretinal surgeon certainly finds it easy to perform PPV when an eye is either pseudophakic or aphakic. PPV in phakic eye carries the risk of lens touch, which might occur in 4%–9% of cases.[3],[4] Lens touch is possible, especially when peripheral retina is approached by vitrectomy instruments during PPV. Examples of such situations are peripheral retinal breaks and presence of anterior proliferative vitreoretinopathy (PVR). In these circumstances, the surgeon needs more space to reach the pathological areas in order to perform the required actions. Furthermore, PPV alone in phakic eye will result in the development and progression of cataract in that eye soon or later. This will necessitate the removal of the cataract by another surgery. This, of course, will add more cost in long term because two separate operations are more costly than a single combined surgery.[5] Moreover, the rate of posterior capsule rupture during the cataract extraction is higher in vitrectomized eyes.[6] Further to that, patients, who undergo two separate surgeries, are exposed twice for the risk to develop intraoperative and postoperative complications such as endophthalmitis, retinal detachment, and suprachoroidal hemorrhage. The risk of those complications is only once if the combined approach is chosen. Prediction of refractive status postcombined surgery is not considered as an issue since an accurate biometry calculation is done with very sensitive and precise equipment taking in consideration a mild myopic shift from PPV itself.[7] Furthermore, vitrectomized eyes are anatomically different as the anterior chamber gets deeper with fluctuation and the zonules are weaker, and therefore, cataract surgery becomes more challenging. Interestingly, the development of posterior capsular opacity is less common after combined procedures in comparison to sequential surgery, 12.5% versus 24.2%.[8] Similarly, the development of iris rubeosis was found to occur less frequent after a combined procedure than after PPV alone, 2% versus 15%.[9],[10] In some patients, silicone oil is used as an intraocular tamponade during PPV, so if cataract surgery is planned for patients with oil-filled eyes, then it is not easy to get accurate biometry calculation and the surgery itself is technically difficult. In addition, some patients, who have a phobia from surgeries, prefer to have the combined procedure instead of exposing themselves twice for such procedures.
As a conclusion, both decisions of combined or sequential surgery have pros and cons. However, for long-term benefits, combined surgery seems to have a better outcome with less disadvantages. Furthermore, if decided to do PPV on phakic eyes without lens extraction, it is always useful to have a biometry calculation of the intraocular lens preoperatively. This will improve the surgical outcome if a decision of lens removal is taken intraoperatively for unexpected reasons.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Norton EW, Machemer R. A new approach to the treatment of selected retinal detachments secondary to vitreous loss at cataract surgery. Trans Am Ophthalmol Soc 1971;69:63-70.  |
| 2. | Ferrone PJ, Harrison C, Trese MT. Lens clarity after lens-sparing vitrectomy in a pediatric population. Ophthalmology 1997;104:273-8. |
| 3. | Elhousseini Z, Lee E, Williamson TH. Incidence of lens touch during pars Plana vitrectomy and outcomes from subsequent cataract surgery. Retina 2016;36:825-9. |
| 4. | Szijarto Z, Haszonits B, Biró Z, Kovacs B. Phacoemulsification on previously vitrectomized eyes: Results of a 10-year-period. Eur J Ophthalmol 2007;17:601-4. |
| 5. | Seider MI, Michael Lahey J, Fellenbaum PS. Cost of phacovitrectomy versus vitrectomy and sequential phacoemulsification. Retina 2014;34:1112-5. |
| 6. | Erçalık NY, Yenerel NM, Sanisoǧlu HA, Kumral ET, İmamoǧlu S. Comparison of intra – And postoperative complications of phaco between sequential and combined procedures of 23-gauge vitrectomy and phaco. Saudi J Ophthalmol 2017;31:238-42. |
| 7. | Lee DK, Lee SJ, You YS. Prediction of refractive error in combined vitrectomy and cataract surgery with one-piece acrylic intraocular lens. Korean J Ophthalmol 2008;22:214-9. |
| 8. | Roh JH, Sohn HJ, Lee DY, Shyn KH, Nam DH. Comparison of posterior capsular opacification between a combined procedure and a sequential procedure of pars Plana vitrectomy and cataract surgery. Ophthalmologica 2010;224:42-6. |
| 9. | Kadonosono K, Matsumoto S, Uchio E, Sugita M, Akura J, Ohno S. Iris neovascularization after vitrectomy combined with phacoemulsification and intraocular lens implantation for proliferative diabetic retinopathy. Ophthalmic Surg Lasers 2001;32:19-24. |
| 10. | Khan R, Khan KN, Rahman R. Is iris neovascularization a complication of phacovitrectomy in patients with proliferative diabetic retinopathy? Invest Ophthalmol Vis Sci 2008;49:2760. |
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