EyeWorld Asia-Pacific September 2012 Issue

20 EWAP CAtArACt/IOL September 2012 Japan’s view on cataract surgery: Combine it with vitrectomy by Matt Young EyeWorld Contributing Editor There’s so much more to combining surgery than a dropped nucleus T hink of modern cataract surgery and you might automatically think of some other terms, like refractive lens exchange or simply refractive surgery. In Japan, doctors are thinking of something seemingly very different: vitrectomy. That might strike U.S. surgeons as odd given that sometimes vitrectomy is what’s needed when cataract surgery goes wrong, resulting in posteriorly dislocated lens material that needs a surgical resolution. But in Japan, for a multitude of reasons, combined cataract and vitrectomy surgery is popular, providing benefits for both patients and surgical staff alike. Origins of combined surgery In Japan, combined cataract and vitrectomy dates back about 20 years, before which combined procedures were not favored, said Shunji Kusaka, MD, professor of ophthalmology, Sakai Hospital, Kinki University Faculty of Medicine, Osaka, Japan. “At that time, people were opposed to the idea of doing combined surgery,” he said. “But [new] research was showing excellent results.” At that time, phaco- emulsification was being introduced in a more widespread fashion in Japan. Meanwhile, Japan’s vitreoretinal surgeons were being trained as good phacoemulsification surgeons. “On our way to training for vitreoretinal surgery, we have to first perform phaco,” said Dr. Kusaka. “After that we can do vitrectomy. For us, performing cataract surgery is an easier procedure compared to vitrectomy. That’s why we don’t have any hesitation about performing simultaneous cataract and vitrectomy surgery.” Fair enough. Japan’s ophthalmologists seem well trained to perform both procedures and at the same time. But why do so? In answering this question, Dr. Kusaka cited four important uses (in order of popularity) of the Stellaris PC (Procedural Choice) Vision Enhancement System (Bausch + Lomb, Rochester, NY, USA), which provides the ability to perform both cataract and vitreoretinal surgery on the same device. The majority of procedures The 20-gauge Stellaris Posterior Vitrectomy Pack Source: Bausch + Lomb The Stellaris PC performed on that machine would be cataract surgery alone. Surgeons also can perform combined surgery—cataract surgery followed by vitrectomy. Then surgeons might use the device for vitrectomy alone. And finally, in rare cases, surgeons could use it to perform unplanned vitrectomy, such as after a cataract surgery that involved a dropped nucleus. Vitrectomy combined immediately afterward with cataract surgery is more popular than vitrectomy alone because of a visual benefit, Dr. Kusaka said. “If the patient is over 50, and we perform vitreous surgery only, the patient will develop cataract afterward,” Dr. Kusaka said. “But if we perform cataract and vitrectomy simultaneously, the patient will not require surgery afterward.” Yusuke Oshima, MD, associate professor of ophthalmology, Osaka University Graduate School of Medicine, Suita, Japan, agreed. “Vitreoretinal disease complicated with dense cataract is one of the challenging situations for vitrectomy because lens opacification often obscures clear fundus visibility during surgery,” Dr. Oshima said. “In addition, cataract progression after lens- preserving vitrectomy is often seen in elder patients and has been recognized as one of the major vision-threatening complications after vitrectomy. These problems challenging to vitrectomy can be easily settled by performing combined phaco/vitrectomy.” Japan’s version of Medicare also is partly responsible for the popularity of the combined procedure. “When you do combined phaco/vitrectomy in Japan, the surgical expense for cataract surgery will be discounted 50% from the original cost,” Dr. Oshima