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      25-Gauge Pars Plana Vitrectomy for Retained Lens Fragments in Complicated Cataract Surgery

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          Abstract

          Purpose: To verify the efficacy of 25-gauge pars plana vitrectomy (PPV) for the management of posteriorly dislocated lens material after complicated cataract extraction and to determine in what patients this approach offers the optimal benefit in terms of efficacy and safety, considering the amount of retained nuclear material and the duration of surgery. Methods: Forty eyes of 40 patients with retained lens fragments undergoing early (within 1 week) or late (within >1 week) 25-gauge PPV were retrospectively reviewed. The amount of dislocated nuclear material was graded by the surgeon intraoperatively, and the patients were divided into two groups according to the nuclear grading: group A (≤50% dropped nucleus) and group B (>50% dropped nucleus). The presence of brunescent nuclear pieces was considered. The outcomes measured included best-corrected visual acuity (BCVA) and postoperative complications such as retinal detachment, cystoid macular edema (CME) and postoperative ocular hypertension or hypotonia. Results: The patients had a mean age of 78 years. The mean preoperative logarithm of the minimum angle of resolution (logMAR) BCVA was 0.57 ± 0.24 (20/80). A significant positive correlation was found between nuclear material grade and PPV duration (R<sup>2</sup> = 0.81, p < 0.0001). None of the patients had dislocation of brunescent nuclear pieces. On postoperative day 1, the mean postoperative intraocular pressure was 16.75 ± 2.7 mm Hg, with no case of ocular hypotonia. At 6 months of follow-up, the mean logMAR BCVA improved to 0.23 ± 0.3 (20/32). Retinal detachment developed in 4 patients (10%), occurring only in patients of group B (p < 0.002). Four patients with late PPV developed postoperative CME, with no case of CME among patients with early vitrectomy (p = 0.014). Conclusion: Removal of dislocated lens fragments after complicated cataract surgery can be effectively managed with 25-gauge PPV, although it appears to be most efficient for cases with a limited amount of dislocated lens material. In consideration of the higher rate of retinal detachment observed in cases of prolonged PPV time, the expected duration of surgery should be taken into account when choosing the best surgical approach. Visual outcomes are not affected by the timing of PPV, whereas early vitrectomy seems to prevent the onset of inflammatory macular edema.

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          Most cited references15

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          A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery1 1The new Transconjunctival Sutureless Vitrectomy System is disclosed to Bausch and Lomb Surgical, St. Louis, MO. The Microsurgery Advanced Design Laboratory (MADLAB) may receive royalties related to the sale of this and other instruments mentioned in the article.

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            Comparison of clinical outcomes and wound dynamics of sclerotomy ports of 20, 25, and 23 gauge vitrectomy.

            To compare the benefits, the risks and the dynamics of port closure in different gauge vitrectomy systems. Prospective, randomized, comparative study of 90 eyes undergoing 20, 23 and 25 gauge (G) vitrectomy for uncomplicated vitreous hemorrhage due to proliferative diabetic retinopathy, vasculitis, trauma, venous occlusions and others. An endoscope was used in five cases of each group to visualize the inside of sclerotomy ports. Vision improved from 0.048 (3/60) to 0.206 (6/24) (p = 0.0021), from 0.069 (4/60) to 0.389 (6/18) (p < 0.0001) and from 0.055 (3/60) to 0.286 (6/24) (p = 0.0010) with 20, 23, and 25-G systems, respectively. Re-bleeds occurred in 4, 1 and 4 eyes of 20, 23 and 25-G systems respectively and post-operative retinal detachment was seen in 2 cases of 20-G system. There were no cases of post-operative hypotony or endophthalmitis seen. With 23 and 25 gauge systems, significant amount of vitreous was seen blocking the inner lip of the sclerotomy ports. The small gauge systems are safe and equally effective than the 20-G system for non-complicated vitreous hemorrhage cases with faster recovery and more comfort for the patient. Increased vitreous clogging with small gauge systems does not extrapolate to an increased risk of complications.
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              Diagnosis and management of lens-induced glaucoma.

              Lens-induced glaucoma may occur as either secondary angle-closure or open-angle glaucoma. Dislocation or swelling of the lens can cause pupillary block and subsequent angle-closure glaucoma. Leakage of soluble lens proteins from a relatively intact cataractous lens can result in a severe secondary open-angle glaucoma (phacolytic glaucoma). Heavy molecular weight protein, believed to be of lens origin, has now been identified in 12 of 12 anterior chamber specimens from such patients. This liberated lens protein can directly obstruct the trabecular outflow pathways. After extracapsular cataract surgery or after lens trauma, liberated fragments of lens material may mechanically impair the drainage of aqueous humor through the outflow channels (lens particle glaucoma). The diagnosis and management of these different lens-induced glaucomas are reviewed. With proper recognition, these glaucomas are promptly cured by the surgical removal of the lens (material).
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                Author and article information

                Journal
                OPH
                Ophthalmologica
                10.1159/issn.0030-3755
                Ophthalmologica
                S. Karger AG
                0030-3755
                1423-0267
                2015
                September 2015
                15 July 2015
                : 234
                : 2
                : 101-108
                Affiliations
                Department of Ophthalmology, Catholic University of Sacred Heart, Rome, Italy
                Author notes
                *Andrea Scupola, MD, Department of Ophthalmology, Catholic University of Sacred Heart - Gemelli Policlinic, Largo Agostino Gemelli, 8, IT-00168 Rome (Italy), E-Mail scupola99@gmail.com
                Article
                434732 Ophthalmologica 2015;234:101-108
                10.1159/000434732
                26183856
                5a0d965d-d1fd-48df-adb6-26efeb1c4f2b
                © 2015 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 07 March 2015
                : 29 May 2015
                Page count
                Figures: 1, Tables: 1, References: 16, Pages: 8
                Categories
                Original Paper

                Vision sciences,Ophthalmology & Optometry,Pathology
                25-Gauge vitrectomy,Late vitrectomy,Retained lens fragments,Early vitrectomy,Cystoid macular edema,Complicated cataract surgery,Retinal detachment,Cataract

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