|Year : 2014 | Volume
| Issue : 2 | Page : 68-73
Combined phacoemulsification and sutureless vitrectomy for treatment of rhegmatogenous retinal detachment
Ahmed Hosni Abd Elhamid
Department of Ophthalmology, Ain Shams University Hospital, Cairo, Egypt
|Date of Web Publication||5-Jun-2015|
Dr. Ahmed Hosni Abd Elhamid
Department of Ophthalmology, Ain Shams University, Cairo
Source of Support: None, Conflict of Interest: None
Purpose: To report the success rate and possible complications of combined phacoemulsification and sutureless 23 gauge vitrectomy for treatment of rhegmatogenous retinal detachment (RRD). Patients and Methods: Thirty patients with RRD were included in the study. All patients were examined for the extent of detachment, number and location of retinal breaks, and degree of proliferative vitreoretinopathy (PVR). Combined phacoemulsification, intraocular lens implantation, 23 gauge vitrectomy, laser retinopexy, and 12% C3F8 injection were done for all patients. All eyes were followed for 3 months. The primary outcome measures were single operation success rate and change in best-corrected visual acuity (BCVA). Any intraoperative and postoperative complications were reported and analyzed. Results: The mean age of the patients was 43.9 ± 10.11 years; mean duration of detachment was 17.3 ± 5.53 days while mean preoperative BCVA measured by logarithm of the minimum angle of resolution (Log MAR) was 2.1 ± 0.71. Single operation success rate was achieved in 25 eyes (83.3%), 5 eyes (16.7%) showed failure of complete attachment after absorption of gas bubble. The mean postoperative BCVA was significantly better than the preoperative value (1.00, 1.1 after 6 weeks and 3 months, respectively, P < 0.01). The most common postoperative complications were reversible corneal edema that occurred in 11 eyes (36.6%), fibrinous uveitis in 8 eyes (26.6%) and posterior capsular opacification in 16 eyes (53.3%). Preoperatively, 1 eye (3.3%) had BCVA ≤1 (Log MAR) in comparison to 17 eyes (56.7%) and 18 eyes (60%) after 6 weeks and 3 months respectively. Conclusion: Combined phacoemulsification and sutureless vitrectomy with gas tamponade is safe and effective single surgical procedure for selected patients with RRD.
Keywords: Cataract, phacovitrectomy, rhegmatogenous retinal detachment
|How to cite this article:|
Elhamid AA. Combined phacoemulsification and sutureless vitrectomy for treatment of rhegmatogenous retinal detachment. Egypt Retina J 2014;2:68-73
| Introduction|| |
Vitreoretinal abnormalities are frequently associated with cataract in elderly patients. Cataract increases in prevalence with age, as do vitreoretinal pathologies, such as macular holes, epiretinal membranes, and retinal detachments.  Most if not all vitrectomy surgeries lead to cataract formation and progression especially if an intraocular tamponading agent is used. The presence of cataract will often necessitate a second operation soon after the vitreoretinal surgery if a lens extraction is not performed simultaneously during the first surgery. Combined lens removal with vitrectomy is routinely done for cases with macular holes, epiretinal membrane and of course if there is a degree of cataract that interferes with proper visualization during vitrectomy. 
In cases of rhegmatogenous retinal detachment (RRD), lens removal may have additional benefits to what was previously mentioned, proper peripheral vitrectomy, and vitreous base shaving with identification of all breaks are the corner stone success factors for retinal reattachment and lens removal may add additional benefit in reaching peripheral retina and vitreous without the fear of touching or hitting the crystalline lens.  Another benefit of combining phacoemulsification to vitrectomy is to avoid rapidly progressive cataract which may hinder proper retinal examination. 
However, there may be additional complications and surgical challenges related to combined surgery.
The aim of this study is to report the efficacy and safety of combined phacoemulsification and vitrectomy with gas tamponade in cases with RRD.
| Patients and Methods|| |
Noncomparative interventional nonrandomized study that enrolled 30 eyes with RRD from January 2012 to August 2013. The inclusion criteria included age 40 years or more, any sex, RRD with one or multiple breaks, proliferative vitreoretinopathy (PVR) less than grade C. The exclusion criteria are patients <40 years (preserved accommodation), PVR grade C, trauma, retinal detachment caused by macular hole or giant retinal tears, any physical or mental problem that prevents proper postoperative positioning and any other causes contributing to drop of vision rather than RRD.
Comprehensive explanation about the disease was done for all patients together with the importance of postoperative positioning. All the possible complications especially recurrence of the detachment were thoroughly explained to the patients with special attention to the benefits of lens removal during the procedure and also the issue of the resulting anisometropia for high myopic patients was discussed.
Preoperatively, All the patients were subjected to best-corrected visual acuity (BCVA) measurement by Snellen chart that was converted to logarithm of the minimum angle of resolution (Log MAR), slit lamp examination, intraocular pressure (IOP) measurement by Goldman applanation tonometry and detailed indirect ophthalmoscopy for the extent of detachment, location, number of retinal breaks and degree of PVR.
Intraocular lens (IOL) power calculation was derived from axial length measurement of the affected eye, but when the retinal detachment prevented satisfactory readings, data for the fellow eye were used.
Standard surgical technique was done for all the patients that included: General anesthesia for 9 eyes and local peribulbar anesthesia for 21 eyes. Sterilization and draping followed by irrigation of the conjunctival sac by 5% betadine solution. Insertion of 23 gauge infusion cannula was done at the beginning of surgery in the lower temporal quadrant 3.5 mm from the limbus. The phacoemulsification was done using DORC Associate phacoemulsification vitrectomy machine (Dutch ophthalmic, Netherland) beginning with two 20 gauge stab corneal incisions followed by ocular viscoelastic device (OVD) injection and 2.8 mm main corneal incision, 5 mm capsulrhexis, hydrodisection and Hydrodelineation, emulsification of the nucleus by chip and flip or stop and chop techniques followed by epinucleus removal and bimanual irrigation aspiration for cortical lens matter, viscoelastic injection to fill the capsular bag followed by injecting a foldable single-piece hydrophobic acrylic IOL in all the eyes with intact posterior capsule, in those eyes with posterior capsular tear (PCT), anterior vitrectomy was done and three pieces foldable hydrophobic acrylic IOL was inserted in the sulcus. OVD removal from behind the IOL was done while keeping some OVD in the anterior chamber followed by closure of the main wound by a single 10\0 stich.
After checking the tip of the infusion cannula, the upper nasal and upper temporal sclerotomies were created.Chandelier light was used in some cases. Core vitrectomy with the aid of wide field visualization system (OCULUS, BIOM) was done, limited peripheral vitrectomy followed by triamcinolone injection and posterior hyaloid removal by active suction with 300 mm hg vacuum level. Bent needle and forceps were used for some cases with adherent posterior hyaloid., then heavy perfluorocarbon (PFC) liquid was injected to flatten the posterior pole till just behind the vascular arcades, peripheral vitrectomy was completed with vitreous base shaving under scleral indentation for 360° followed by identification of all the breaks, marking them by light diathermy and trimming of any rolled edges of the breaks with removal of flaps for flap tears. More PFC was injected to flatten the retina up to the ora serrate; checking for any residual traction after PFC injection was a critical step. Retinopxy of all original and iatrogenic breaks was carried out by endolaser as shown in [Figure 1] and [Figure 2]. Air - PFC exchange was done followed by flushing the eye with 60 ml of 12% C3F8. Removal of the remaining viscoelastic substance from the anterior chamber was done, followed by stromal hydration of the main and side wounds. Subconjunctival injection of dexamethasone was given followed by instillation of antibiotic steroid ointment and eye patching.
|Figure 1: (a) Intraoperative view of one patient showing retinal detachment and upper nasal horseshoe retinal tear (b) intraoperative view showing peripheral vitrectomy and trimming of the tear flap.(c) laser retinopexy of the tear after flattening of the retina (d) postoperative view after gas bubble absorption showing totally flat retina|
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|Figure 2: (a) Intraoperative view of another patient with rhegmatogenous retinal detachment (b) laser retinopexy around lower retinal tear (c) postoperative view showing flat retina|
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All the patients are instructed for certain postoperative positioning according to the location of retinal breaks (head elevation for upper breaks and face down position for lower breaks which is maintained strictly for the first 48 hours then for 2 hours followed by rest for 15 minutes for the following 5 days). All the patients received postoperative treatment in the form of combined steroid antibiotic eye drops hourly with a gradual decrease in frequency along 1-month. Follow-up of all eyes was done after 1-day, 4 days, 1-week, 2 weeks, 1-month, 6 weeks and 3 months. At each visit BCVA was measured in addition to complete ophthalmic examination, ophthalmoscopy if possible with evaluation of the height of the gas bubble and IOP measurement with applanation tonometry.
The primary outcome measures were change in BCVA and anatomic success which is retinal reattachment after 3 months. Anatomic failure means failure of attachment of the retina after the gas bubble absorption, recurrence is considered if the retina became attached for some time after the gas bubble absorption then redetached again. Any intraoperative and postoperative complications were reported and analyzed.
preoperative characteristics such as age, duration of RD, and number of breaks are expressed in mean values and standard deviation. Success rate and complications are expressed in percentage. Visual acuity (VA) was analyzed by means of the Log MAR score. The Log MAR score is derived by taking the logarithm (base 10) of the fraction of the Snellen VA. A score of 0.0 in Log MAR is equivalent to a VA of 20/20 on the Snellen acuity chart, whereas a score of 1.0 is equivalent to 20/200. Conversion of counting fingers and hand movements were given the values of (2 Log MAR) and (3 Log MAR), respectively.
| Results|| |
The preoperative characteristics of all eyes are summarized in [Table 1]. The mean age was 43.9 ± 10.11 years (rang from 39 to 54 years), 17 patients (56.6%) were males and 13 (47.3%) were females. RRD was total in nine eyes and subtotal in 21 eyes, the total number of breaks was 45 (mean was 1.5), the distribution of these breaks was shown in [Table 1], macula was detached in 26 eyes (86.7%) and attached in 4 eyes (13.4%), the mean preoperative BCVA measured by Log MAR is 2.1 ± 0.71 and the mean duration of the detachment since beginning of patient Symptoms was 17.3 ± 5.53 days.
Complete retinal attachment was achieved in 25 eyes (83.3%). 5 eyes (16.7%) showed failure of retinal attachment after absorption of gas bubble as shown in Chart 1. The reason for failure of retinal reattachment was missed open breaks in 3 eyes (10%) and PVR in 2 eyes (6.7%).
Second surgical intervention with 360 scleral depression to identify any open breaks, removal of epiretinal membranes with silicone oil injection and more endolaser retinopexy was done for all the 5 eyes. Silicone oil was removed 3 months after the second surgery, and the retina remained attached in all the five eyes for an average follow-up period of 4.6 months.
Change in best-corrected visual acuity
The mean preoperative BCVA was 2.1 ± 0.71 measured by Log MAR while it was 1.1 ± 0.75 after 6 weeks (HSS P < 0.01paired t-test). After 3 months the mean BCVA was 1.00 ± 0.68 (P < 0.01) [Table 2].
Chart 2 shows that 26 eyes (86%) had got BCVA between 1.5 and 3 (Log MAR) preoperatively while only 5 eyes (16.7%) had this level after 6 weeks and none of the eyes had this level after 3 months. Three eyes (10%) had preoperative BCVA level between 1.5 and 1 while 8 (26.7%) and 12 (40%) eyes had this level after 6 weeks and 3 months, respectively. On the other hand, only 1 eye (3.3%) had BCVA ≤1 preoperatively in comparison to 17 eyes (56.7%) and 18 eyes (60%) after 6 weeks and 3 months, respectively.
[Table 3] summarizes the different intraoperative and postoperative complications. Posterior capsular tears (PCTs) occurred in 4 eyes (13.3%) which was managed by anterior vitrectomy and three pieces acrylic sulcus fixated IOL (being sure of its centration at the end of surgery with no gas bubble escaping to the anterior chamber). Intraoperative iris/IOL capture occurred in 7 eyes (23.3%) with successful intraoperative repositioning into the capsular bag. Iatrogenic retinal tears were present in 5 eyes (16.6%). As regards to the postoperative complications, the most common complication was significant posterior capsular opacity (PCO) that occurred in 16 eyes (53.3%), all of them needed posterior capsulotomy. Reversible corneal edema was found in 11 eyes (36.6%), fibrinous uveitis occurred in 8 eyes (26.6%) which were treated with intensive topical steroids and resolved within 1-week. Partial posterior synechia occurred in 6 eyes (20%). Transient increase in IOP occurred in 5 eyes (16.6%) while transient ocular hypotony occurred in only 1 eye (3.3%), postoperative IOL capture was found in 2 eyes (6.6%).
Nonsignificant epimacular membrane occurred in In one eye (3.3%).
| Discussion|| |
Combined cataract extraction and vitrectomy was traditionally done as an initial need to remove the opaque lens in order to maximize visualization during vitrectomy surgery.  Starting in the late 1980s, numerous authors reported success with combined surgery and IOL implantation. Pars plana lensectomy-vitrectomy followed by IOL implantation in the sulcus through a limbal incision was described, followed later on by extracapsular cataract extraction with IOL placement into the sulcus or capsular bag prior to vitrectomy.  As cataract surgery itself evolved, phacoemulsification became the preferred method for cataract extraction. Combining phacoemulsification prior to vitrectomy has proved successful and allows tight wound closure during vitrectomy as well as permitting IOL implantation within the capsular bag. 
One should think about the pros and cons of combining phacoemulsification with vitrectomy for retinal detachment especially for those with clear lenses. First will cataract appear after vitrectomy and if yes how soon? Definitely cataract formation and progression is one of the most common complications after vitrectomy surgery, thereby interfering with visual gain from the initial surgery.  Long-term follow-up on diabetic patients who were left phakic following vitrectomy showed that up to 75% of them developed postoperative cataracts. Following vitrectomy for macular hole surgery, the incidence of new cataract or progression of preexisting lens opacities is similarly high and has been reported as high as 100% in one study. Progressive cataract following vitrectomy for macular pucker surgery is problematic as well, with the incidence reported up to 65% in one series, also cataract progression after vitrectomy for RRD ranges from 70 to 90%. 
The pathogenesis of cataract formation following vitrectomy is unclear, but numerous factors have been described, including preexisting cataract, advancing age, altered lens metabolism, light toxicity from the operating microscope, diabetes, use of intraocular gas or silicone oil, and surgical trauma, so in most if not all the cases another surgery will be needed with more cost for the patient and health authorities and subsequent exposure to the risk and complications of anesthesia.
Lens removal during vitrectomy for repair of retinal detachment allows better visualization of the peripheral vitreous and retina with subsequent through and careful trimming and shaving of vitreous base and proper identification of all retinal breaks and their treatment without being anxious of hitting the lens and inducing cataract, on the other hand, cataract surgery in vitrectomized eye carries special risks like deep anterior chamber with diffusion deviation syndrome, difficult pupillary dilation and liability of PCTs and zonular dehiscence. 
On the other aspect, combined surgery is known to have some disadvantages like longer surgical time with subsequent more trauma to the cornea and liability for edema but this factor could be eliminated by surgeon experience, modern machines, and sutureless techniques as in this study with shorter time taking in consideration that all the lenses in this study were soft lenses with low U\S power and therefore less trauma to the corneal endothelium.
The success rate in this study was 83.3% which was comparable to smith et al. (88.2%), Sharma et al. (84%), Campo et al. (88%). [10, 11, 12] All the previous studies were designed for vitrectomy only without scleral buckle. Open missed breaks were a cause of failure in 3 (10%) eyes which is slightly more than other studies like Brazitikos et al. (1%), Campo et al. (6%), and Smith et al. (0%). The explanation for this relatively high number of open breaks may be attributed to the imperfect visualization of some areas of the peripheral retina due to corneal edema related to the main wound of phacoemulsification. Two eyes (6.6%) suffered PVR in the form of dense epiretinal membrane causing retinal star folding with macular detachment, this percentage was lower than in other studies and this could be explained by the shorter follow-up period in this study in comparison to other studies and also the use of 23 gauge sutureless vitrectomy system that may lead to less postoperative inflammation and more stable IOP during surgery and subsequently less disturbance of blood ocular barrier and hence less postoperative PVR.
Fibrinous uveitis occurred in 8 (26.6%) eyes which is comparable to other studies; in general many factors can cause fibrinous uveitis in combined surgery as more time, even though the anterior chamber remains stable in most of the time, some fluctuation in anterior chamber depth sometimes occurs either during air fluid, air PFC or during gas injection that can lead to iris trauma and subsequent inflammation. Other factors related to laser retinopexy especially for anterior breaks near the ciliary body. All these eyes were intensively treated with frequent doses of topical steroids with cycloplegia provided that the IOL is stable in the capsular bag. Close monitoring of this postoperative inflammation is recommended to watch the response to medical treatment and to rule out any suspicious of infection; the inflammation had been resolved in all eyes without serious effects rather than localized areas of posterior synechia.
Posterior capsular opacity was the most common reported postoperative complication in this study, which is most likely secondary to gas bubble contact with the posterior capsule and to a lesser extent due to more postoperative inflammation. Many surgeons prefer to perform posterior capsulotomy during surgery to avoid dense PCO and subsequent drop of vision postoperatively, this step was not done here for fear of enlargement of this posterior capsulotomy and possibility of either air or gas escape to anterior chamber which can cause keratopathy, IOL decenteration or under fill of the posterior vitreous compartment. Eyes that suffered PCO had undergone posterior capsulotomy by YAG after 3 months from the surgery without any complications; surgical capsulotomy was done for eyes that needed second surgery. Postoperative IOL iris capture occurred in 2 eyes (6.6%), these eyes had PCT and sulcus fixated IOL. Successful repositioning had been done for them.
A limitation of this study is that it lacks a comparative group for which vitrectomy was done followed by cataract removal in another session provided that the lens clarity permits doing vitrectomy. Prospective studies comparing the visual, anatomical, and refractive outcomes of combined surgery with that of vitrectomy and subsequent cataract surgery are required.
| Conclusion|| |
Some patients with RRD requiring vitrectomy have coexisting cataract and also, vitrectomy itself can induce cataract. Combined phacoemulsification and vitrectomy is a safe and effective choice in selected patients. The combined procedure should be considered in patients with already significant cataract and coexisting RRD, those who are expected to have rapid cataract progression following vitrectomy, such as older patients, those who will have intraocular gas tamponade and in some patients with anteriorly located peripheral retinal tears. Combined surgery maximizes surgical visualization, offers more rapid visual rehabilitation and decreases the need for the second surgery.
| Acknowledgment|| |
The author has no financial or proprietary interest in any material or method mentioned.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]