EyeWorld Asia-Pacific March 2014 Issue

March 2014 9 EWAP FEAturE Views from Asia-Pacific ONG Sze Guan, MBBS, FRCS(Ed), FRCOphth, FAMS Senior Consultant, Vitreo-Retinal Service, Singapore National Eye Centre 11 Third Hospital Ave., Singapore 168751 Ong.sze.guan@snec.com.sg T his topic has become increasingly discussed at meetings and forums worldwide, although in reality it has existed for a long time, since the evolution of cataract and vitrectomy surgery utilizing small incisions and creating small wounds. Like all trends in surgery there are pros and cons in doing combined procedures. Combined cataract surgery with vitrectomy is commonly performed outside the United States. In the Asia-Pacific region, surgeons are trained for both phacoemulsification and vitreoretinal surgeries due to healthcare and societal needs. As such, most vitreoretinal surgeons are already competent in phacoemulsification at the end of their training and able to handle both. In the present era, certainly combined phacoemulsification and vitrectomy using minimally invasive instrumentation is established for macular conditions like macular holes, epiretinal membranes and vitreomacular traction syndromes. These condition affect central vision and progression of cataract if not removed initially and will prolong recovery and degrade visual quality. In diabetic vitrectomy, however, prior to anti-VEGF therapy, the tendency is to preserve the lens as a barrier against neovascularization and secondary rubeosis and glaucoma. Nowadays this risk has been significantly reduced with anti-VEGF therapy which can be used prior to or in conjunction with vitrectomy. As such there is greater tendency to combine phacoemulsification with vitrectomy in diabetic eyes. In retinal detachments, in general, I prefer to deal with the retinal condition first and then worry about the lens and secondary cataract later. Retinal detachments are so varied in nature and presentations each case must be assessed on its own merits. Factors to consider are the age of the patient, the severity of the retinal detachment and degree of cataract. However, as there is now a trend towards primary vitrectomy for retinal detachments, I expect that combined cataract and vitrectomy for retinal detachments will similarly be on the increase. Combined surgery has been shown to be safe and effective for the patient and have reasonably predictable outcomes. Ultimately the decision should be based on the underlying condition, available resources and the training of the surgeon. Editors’ note: Dr. Ong reported no financial interests related to his comments. Vignesh RAJA, FRCS, FRCOphth, FRANZCO Consultant ophthalmologist, Sir Charles Gairdner Hospital Hospital Avenue, Nedlands, Perth, Australia 6009 Tel. no. +61 470401570 Fax no. +61 9346 4146 drvigneshraja@gmail.com I n situations where a patient has dual pathology of cataract combined with an epiretinal membrane or a macular hole, ophthalmologists can either choose to do a sequential procedure of cataract removal followed by vitrectomy or vice versa or a single combined procedure. Both approaches have their pros and cons. I. SEQUENTIAL SURGERY A. Cataract removal followed by vitrectomy Pros: 1. Straight forward cataract removal 2. Can be done using a temporal incision 3. Clear optical media for the retinal surgeon at the time of vitrectomy 4. Good wound stability at the time of retinal surgery 5. Posterior capsulectomy using a vitrector can also be done at time of subsequent vitrectomy Cons: 1. Two-step procedure may result in inconvenience for patients 2. Despite careful counseling of the guarded prognosis owing to macular pathology, there is always a certain degree of expectation following any ophthalmic surgery especially cataract removal, which could lead to patient disappointment B. Vitrectomy followed by cataract Pros: 1. Good red reflex during subsequent cataract surgery 2. Premium IOLs can be considered if macular pathology resolved 3. Realistic patient expectations Cons: 1. Cataract might impede retinal surgeon’s view during initial vitrectomy 2. Risk of lens touch, zonule damage during initial vitrectomy 3. Post-vitrectomy cataract removal can be very challenging with very deep anterior chamber during surgery, zonular instability or risk of dropped nucleus in case of inadvertent lens touch or capsule rupture during prior vitrectomy II. COMBINED PROCEDURE Pros: 1. Single procedure convenient for the patient 2. Visual results potentially better because both pathologies are addressed in one sitting 3. Good retinal view with removal of cataract Cons: 1. In combined cases, usually corneal incision is made superiorly which is not optimal for astigmatism correction. Alternatively, one could do a temporal incision cataract surgery and then move to the head end to proceed with the vitrectomy. 2. Poor corneal wound stability during port placement after cataract surgery. One can prevent this by creating 3-step square corneal incisions or by pre-placing the vitrectomy ports prior to the cataract surgery but loss of vitreous humor during this step can cause the eye to behave like a post-vitrectomy eye during cataract removal. Editors’ note: Dr. Raja has no financial interests related to his comments.