EyeWorld Asia-Pacific March 2014 Issue

3 EWAP March 2014 Letter from the Editor Dear Friends A t times the areas of concern of our retinal colleagues are worlds apart. Occasionally, however, the orbits of our planets coincide in areas of common interest. This issue of EyeWorld Asia-Pacific considers patients who present with both cataract and significant epiretinal membrane. We have sought a wide range of opinions both from vitreoretinal and anterior segment surgeons. A combined procedure is certainly attractive from a patient’s perspective in that only one operation is required. Scheduling surgery for two surgeons however is complex and there are few surgeons who are highly skilled in both procedures. It is common practice therefore to perform a staged approach with either the cataract or vitrectomy performed as the initial procedure. In circumstances where the cataract is dense enough to preclude adequate visualization or if the epiretinal membrane is of doubtful significance, it makes sense to proceed with cataract surgery as the initial procedure. On the other hand, if the lenticular changes are minor or nonexistent, then vitrectomy and removal of the epiretinal membrane is typically the primary procedure. The anterior segment surgeon is then faced with performing cataract surgery in a post-vitrectomy eye. This poses surgical challenges which are covered in some detail. In my opinion, it is preferable not to delay the cataract surgery unnecessarily as a very brunescent cataract can be difficult in a post-vitrectomy eye. Typically, the chamber can be quite deep and the iris relatively floppy due to lack of support by the vitreous. Paying attention to well balanced fluidics is essential in managing these cases as well as being prepared for the unexpected as there may be zonular or even capsular defects associated with the earlier procedure. If capsular tear occurs during cataract surgery with presentation of vitreous, one can approach vitrectomy either from a limbal or pars plana approach. Certainly, the pars plana approach has advantages and with smaller-gauge vitrectomy and better trochars is a procedure that can be within the domain of anterior segment surgeons. Courses and wetlabs on pars plana vitrectomy for the anterior segment surgeon are increasingly popular. Personally, I still believe that the limbal approach can be equally effective. Separating the infusion and vitrectomy probe is critical in performing a vitrectomy. Using 25-gauge vitrectomy probes allows the surgeon to perform the vitrectomy below the plane of the iris, thus avoiding pulling vitreous anteriorly similar to a pars plana approach. A 25-gauge instrument that can be inserted through a sideport incision is more maneuverable and less disruptive if vitrectomy is required during anterior segment surgery. The ability to perform a limited anterior vitrectomy by the pars planar approach does not encourage anterior segment surgeons to consider more complex posterior segment procedures such as dealing with a dropped nucleus which should remain the domain of the expert vitreoretinal surgeon. Finally, if vitrectomy is required, one of the difficult areas in the past has been determining whether all remaining strands have been removed. There is no doubt that intracameral triamcinolone is of great benefit in this situation and the articles in this issue contain valuable advice on the correct use and preparation of triamcinolone in these circumstances. Although the anterior vitreous is not a region where the anterior segment surgeon typically chooses to venture, occasionally it is necessary, particularly with the management of trauma and anterior segment reconstruction. I hope this issue is helpful when these difficult cases are encountered. Warmest regards Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific EYEWORLD ASIA-PACIFIC EDITORIAL BOARD C HIEF MEDICAL EDITOR Graham BARRETT, Australia MEMBERS Abhay VASAVADA, India ANG Chong Lye, Singapore CHAN Wing Kwong, Singapore CHEE Soon Phaik, Singapore Choun-Ki JOO, Korea Hiroko BISSEN-MIYAJIMA, Japan ASIA-PACIFIC CHINA EDITION Editors-in-Chief ZHAO Jialiang ZHAO Kan Xing Deputy Editor HE Shouzhi Assistant Editor ZHOU Qi ASIA-PACIFIC INDIA EDITION Regional Managing Editor S. NATARAJAN ASIA-PACIFIC KOREA EDITION Regional Editor-in-Chief Hungwon TCHAH Regional Managing Editor Chul Young CHOI Hungwon TCHAH, Korea John CHANG, Hong Kong Johan HUTAURUK, Indonesia Kimiya SHIMIZU, Japan Pannet PANGPUTHIPONG, Thailand Prin ROJANAPONGPUN, Thailand Ronald YEOH, Singapore S. NATARAJAN, India YAO Ke, China Y.C. LEE, Malaysia