Combined phaco- vitrectomy - mreh200.org.uk Simcock.pdf · Exeter macular hole study Combined...
Transcript of Combined phaco- vitrectomy - mreh200.org.uk Simcock.pdf · Exeter macular hole study Combined...
Combined phaco-
vitrectomy
Peter Simcock FRCP FRCS FRCOphth
West of England Eye Unit
Exeter
SHO MREH 1987
“Beautiful ECCE’s”
Registrar MREH 1990 - 1992
Phaco “being tried” at MREH
“Unlikely to catch on”
Senior Registrar Charing Cross and
Moorfields 1993 - 1995
SHO taught me Phaco!
“Phaco is the way to go”
VR Fellow MREH 1995 -1996
Fantastic training in VR
Post vitrectomy cataract sent to anterior segment team
Vitrectomy and cataract
Nuclear sclerosis
Formed gel protective
Increased in myopia
Increased post vity
Gradual onset
Gas cataract
Large gas fill
Posterior sub capsular
Immediate effect
Patient perspective
Has “big” vitreoretinal operation in hospital
May need to posture post op
Uncomfortable
Develops index myopia
Change in glasses
Change in glasses
Referred back to hospital
Back in for cataract operation
Surgeons perspective
Difficult cataract surgery
Lens / zonules damage
High myopes
A/C instability and variable pupil size
BUT
Modern phaco machines have better A/C
stability
Ways of avoiding iris bounce
Szijarto Z et al Phacoemulsification on previously
vitrectomized eyes: Results of a 10-year-period. Eur
J Ophthalmol. 2007 Jul-Aug;17(4):601-4
143 eyes
Per-op
93% deep or fluctuating A/C depth
9% PC rupture
5% incomplete capsulorhexis
Post-op
6% retinal detachment
Sunderland Eye Infirmary
Ghosh S et al. Lens – iris diaphragm retropulsion
syndrome during phacoemulsification in
vitrectomized eyes J Cataract Refract Surg 2013
Dec 39(12):1852-8
Case series of 75 eyes
53% had evidence of iris diaphragm retropulsion
syndrome
Cataract National Dataset electronic multicentre
audit of 55,567 operations: risk stratification for
posterior capsule rupture and vitreous loss
Eye 2008
Age
Male gender
Glaucoma
Diabetic retinopathy
White cataract
Poor fundal view
Phacodonesis / PXF
Small pupil
Axial length >26mm
Inability to lie flat
Trainee surgeon
Use of alpha blocker
Private practice perspective
Some people may not be so keen on
combined surgery!
Combined surgery – historical
perspective
If no cataract, leave lens and do vitrectomy alone
If mild cataract but good view of fundus, leave lens and do vitrectomy alone
If sufficient cataract to impair fundal view, do vitrectomy and lensectomy (posterior approach to lens)
Lens in sulcus if sufficient capsule support
AC IOL if insufficient capsule support
May require large corneal section
Combined surgery – with advent of
good phaco technique
If no cataract, leave lens and do vitrectomy
alone
If mild cataract but good view of fundus, leave
lens and do vitrectomy alone
If sufficient cataract to impair fundal view, do
phaco vitrectomy (anterior approach to lens)
Lens in capsular bag
Small corneal section
Why not routinely remove the lens in
a presbyopic patient undergoing
vitrectomy?
Lens already lost ability to accommodate
Cataract formation almost inevitable after
vitrectomy
Avoid patient having to return for further
surgery
Possibility of emmetropia
1997 Exeter
Keen newly appointed consultant
Why not do phaco vitrectomy on presbyopic
patients?
Would also enable more complete vitrectomy
Would also enable very large gas fills with no
worries about gas cataract
Perhaps would not need to posture for patients
having surgery for macula hole?
Tornambe PE et al. Retina, 1997;17(3):179-85. Macular hole
surgery without face-down positioning
Simcock PR, Scalia S. Acta Ophthalmol Scand. 2000
Dec;78(6):684-6 Phaco-vitrectomy for full-thickness macular
holes.
Simcock PR, Scalia S. Br J Ophthalmol. 2001
Nov;85(11):1316-9. Phaco-vitrectomy without prone posture
for full thickness macular holes. (71 citations)
Exeter macular hole study
Combined phaco-vitrectomy surgery
With posture 13 patient
Without posture 20 patients
Results
With posture 85% hole closure
Without posture 90% hole closure
“The whole is greater than the
sum of it’s parts”
From Zen Buddism
Ling R, Simcock P et al. Presbyopic phacovitrectomy.
Br J Ophthalmol. 2003 Nov;87(11):1333-5.
90 eyes (28 RRD, 44 macular holes, 11 ERM, 7
other)
13% fibrinous uveitis
1% IOL / pupil capture
Smith M, Raman SV, Pappas G, Simcock P, Ling R, Shaw
S. Phacovitrectomy for primary retinal detachment repair
in presbyopes.
Retina. 2007 Apr-May;27(4):462-7.
93 eyes, 88% reattachment rate with one op
16% fibrinous uveitis
8% IOL / pupil capture
How to avoid IOL / pupil capture
Nothing new – keep capsulorhexis size
smaller than the optic
Avoid strong post-operative mydriatics
Tropicamide nocte for 1 week
Rahman R, Rosen PH. Pupillary capture after combined management of
cataract and vitreoretinal pathology. J Cataract Refract Surg 2002;28:1607-
1612
How to avoid fibrinous uveitis
Anterior chamber stability = minimal inflammation
Be aware of pressures on either side of posterior capsule at all time
Be aware of infusion pressures and if infusions are on or off
Pred forte 2hrly for 2 days then q.i.d.
Endo laser rather than cryo
DO NOT ALLOW ANTERIOR CHAMBER TO COLLAPSE
Recent developments
Better phaco machines
Good AC stability
Microincision phaco / Bimanual phaco
Better vitrectomy machines
Good pressure control
Designed for combined surgery
23g vitrectomy
Less inflammation
Less entry site breaks
Valved trocars to maintain pressure
Manchester Royal Eye Hospital
Dhawahir-Scala FE et al. Retina 2008 Jan
28(1):60-5
To posture or not to posture after macular hole
surgery
28 eyes
One first night of face down posture
No need to posture if > 70% gas fill on first post op
day
Manchester Royal Eye Hospital
Jalil A et al. Eye 2014 Apr 28(4):389-9
Microincision cataract surgery combined with
vitrectomy: a consecutive case series
52 eyes with 1.8mm microincision (MICS) cataract
surgery and vitrectomy
2 eyes “significant inflammation”
No lens decentration
Conclusion – “safe technique”
Current technique
Insertion of 23g trocars
Corneal incision (no sutures)
Phaco and IA
Vitrectomy
IOL insertion
Gas (if needed)
Current practice
Macular holes Phaco vity on everyone
Only posture large holes
Retinal detachment Slightly increased risk of PVR
May be difficult to get accurate biometry
Vity only
Epiretinal membrane Phaco vity on nearly everyone
Diabetes Vity only
Increased risk of inflammation, rubeosis,