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      Vitrectomy versus Phaco-vitrectomy

      Oman Journal of Ophthalmology

      Wolters Kluwer - Medknow

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          Abstract

          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.

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          Most cited references 9

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          Cost of phacovitrectomy versus vitrectomy and sequential phacoemulsification.

          To evaluate and compare the cost of combined pars plana vitrectomy and phacoemulsification/intraocular lens implantation (phacovitrectomy) to a sequential approach to the surgical procedures for patients with an indication for vitrectomy and a visually significant cataract.
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            Comparison of Posterior Capsular Opacification between a Combined Procedure and a Sequential Procedure of Pars Plana Vitrectomy and Cataract Surgery

            Purpose: To compare posterior capsular opacification (PCO) between a combined procedure and a sequential procedure of pars plana vitrectomy (PPV) and cataract surgery (CS). Methods: The medical records of 89 eyes of 85 patients who underwent PPV and CS were retrospectively reviewed. There were 56 eyes of 52 patients with a combined PPV and CS (the combined surgery group), and 33 eyes of 33 patients with CS in a previously vitrectomized eye (the sequential surgery group). The control group was comprised of 130 eyes of 102 patients who underwent CS alone. All patients were followed up for at least 1 year after CS. The major outcome measures were the PCO rate and the interval between CS and PCO formation. There were no significant differences in age and the incidence of diabetes among the 3 groups. Results: The PCO rate checked at 1 year after CS was 12.5% (7/56) in the combined surgery group, 24.2% (8/33) in the sequential surgery group, and 4.6% (6/130) in the control group. The differences in the PCO rate between the subgroups as well as among the 3 groups were statistically significant (p < 0.05). There were no significant differences in the interval between CS and PCO formation among the 3 groups. Conclusion: This study demonstrates that the PCO rate may be lower in patients who have a combined procedure of PPV and CS than in those who have a sequential procedure.
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              Phacoemulsification on previously vitrectomized eyes: results of a 10-year-period.

              To provide an overview of intraoperative and postoperative complications during phacoemulsification cataract surgery and to evaluate the visual results in patients having pars plana vitrectomy (PPV) with 10 years of follow-up.
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                Author and article information

                Journal
                Oman J Ophthalmol
                Oman J Ophthalmol
                OJO
                Oman Journal of Ophthalmology
                Wolters Kluwer - Medknow (India )
                0974-620X
                0974-7842
                May-Aug 2019
                : 12
                : 2
                : 71-72
                Affiliations
                Department of Ophthalmology, Vitreoretinal Unit, Sultan Qaboos University Hospital, Muscat, Oman
                Author notes
                Address for correspondence: Dr. Ahmed Sulaiman Al-Hinai, Senior Consultant, Department of Ophthalmology, Vitreoretinal Unit, Sultan Qaboos University Hospital, Muscat, Oman. E-mail: dralhinai@ 123456hotmail.com
                Article
                OJO-12-71
                10.4103/ojo.OJO_105_2019
                6561050
                Copyright: © 2019 Oman Ophthalmic Society

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

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                Ophthalmology & Optometry

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