ACTA OPHTHALMOLOGICA SCANDINAVICA 2005
Combined phacoemulsification and pars plana vitrectomy for macular hole treatment Ioannis P. Theocharis, Anastassia Alexandridou, Nasser Jadidi Gili and Zoran Tomic Department of Ophthalmology, University Hospital, Uppsala, Sweden
ABSTRACT. Purpose: To assess the outcome of simultaneous phacoemulsification, pars plana vitrectomy and intraocular lens (IOL) implantation in eyes with macular hole. Methods: A retrospective study was conducted in 38 eyes (36 patients) after combined phacoemulsification, insertion of a posterior capsule IOL and pars plana vitrectomy. Results: The macular hole was successfully closed in 32 of the 38 eyes (84%). In six eyes (16%) the hole failed to close and one eye underwent a second operation. Vision improved by two or more Snellen lines in 29 eyes (73%), there was no change in seven eyes (18%), and visual acuity decreased in two eyes (5%). Intraoperative and postoperative complications included retinal tears in nine eyes (24%), posterior capsule rupture in two eyes (5%), transient postoperative increase of intraocular pressure in eight eyes (21%), and posterior capsule opacification in five eyes (13%). Conclusion: Combining phacoemulsification, IOL insertion and pars plana vitrectomy for macular hole repair can reduce the need for cataract surgery in the future, decrease costs, shorten postoperative recovery time and allow for clearer intraoperative visualization, making the procedure safer and more effective. Key words: combined phacoemulsification – pars plana vitrectomy – macular hole – intraocular lens
Acta Ophthalmol. Scand. 2005: 83: 172–175 Copyright # Acta Ophthalmol Scand 2005.
doi: 10.1111/j.1600-0420.2005.00417.x
Introduction Kelly & Wendel (1991) were the first to report that vitreous surgery can improve the visual outcome in eyes with macular hole. Complications related to the surgery included an increase in the size of the macular hole, mottling of the retinal pigment epithelium, and vascular occlusion ret-
172
inal tears or/and retinal detachment. The incidence of retinal tears is relatively high because an intraoperative and traumatic creation of posterior vitreous detachment is a critical step in the procedure. The most common complication of macular hole surgery in phakic eyes is nuclear sclerotic cataract progression (Kotecha et al. 2000). In Thompson’s
series, 75% of the eyes required cataract extraction within 2 years of macular hole surgery (Thompson et al. 1995). In Leonard’s series, 75% of eyes followed for 1 year and 95% of eyes followed for 2 years developed progressive nuclear sclerotic cataract (Leonard et al. 1997). Accelerated cataract formation following vitreoretinal surgery may be the result of accidental mechanical injury to the lens, or untoward physiological effects of intraocular irrigating solutions, or prolonged exposure to gas during or following the procedure (D’Amico 1994). Progressive nuclear sclerosis of the lens is a very common complication after vitrectomy and, as pre-existing opacities make macular hole repair difficult to achieve, we prefer to combine pars plana vitrectomy with cataract extraction in one operation. This improves the operative view, reduces the need for a second procedure and enhances postoperative visual rehabilitation at a reduced cost. In this retrospective study, we report the visual outcome, as well as the intraoperative and postoperative complications, of combining phacoemulsification and posterior capsule intraocular lens (IOL) implantation with pars plana vitrectomy in eyes with macular hole.
Patients and Methods We studied 38 eyes (21 right and 17 left) in 36 patients in which a simultaneous phacoemulsification, vitrectomy for macular hole and acrylic IOL insertion
ACTA OPHTHALMOLOGICA SCANDINAVICA 2005 had been performed by three vitreoretinal surgeons at our clinic between January 2001 and December 2002. Most of the patients had been referred to our clinic from other hospitals. Patient demographics, including age, sex, extent of cataract, duration of macular hole before surgery, stage of macular hole, pre- and postoperative visual acuity (VA), length of follow-up, complications and subsequent treatment (e.g. second operations, Nd:YAG laser) were recorded. Doctors or nurse specialists performed the Snellen VA test. We evaluated the macular hole using slit-lamp biomicroscopy with a 60-dioptre lens or contact lens biomicroscopy. Ocular coherence tomography (OCT) was performed in uncertain cases before the surgical procedure and/or during the follow-up period. Patients were informed preoperatively about the combined procedure and the option of ‘vitrectomy only’ as an alternative. All patients received local anaesthesia induced by peribulbar injection. Posterior segment surgeons familiar with the phaco technique performed the combined procedures both the phacoemulsification and vitrectomy surgeries. A clear corneal 2.75-mm incision was created at the 12 o’clock position and a continuous circular capsulorhexis was performed followed by hydrodissection of the lens. A standard phacoemulsification was performed and the residual cortex was removed by irrigation/ aspiration. The incision was sutured with a 10.0 nylon suture. Preparation for three-port pars plana vitrectomy was made 3.5 mm from the corneoscleral limbus. The vitreoretinal procedure performed included vitrectomy, peeling of the posterior hyaloid membrane, fluid/air exchange, staining of the internal limiting membrane (ILM) with 2.5mg/ml indocyanine green (ICG), air/ fluid exchange and peeling of the ILM. Epiretinal membrane removal was performed in one eye and endophotocoagulation was added when retinal tears developed. An acrylic foldable IOL with a 6.5-mm optical diameter was inserted in the capsular bag. In one eye, the IOL was placed into the ciliary sulcus because of posterior capsular rupture. In two eyes with retinal tears, scleral buckling was performed as a part of the same procedure. Finally, 13% C3F8 gas/fluid exchange was performed in all eyes. The patients
were instructed to remain in a facedown position for 24 hours, followed by prone positioning for 45 min per hour for 1 week postoperatively. Standard anti-inflammatory treatment with cortisone eye drops was prescribed for a 2-week period after the operation.
Results The patients ranged in age from 49 to 82 years (mean 68 years), and comprised 29 women and seven men. All of the patients preferred the combination of vitrectomy with lens extraction rather than vitrectomy alone. The duration of the macular hole ranged from 1 to 24 months (mean 6 months). The preoperative macular hole was graded as stage 2 (eight eyes), stage 3 (26 eyes) or stage 4 (four eyes), using the Gass classification. Follow-up ranged from 3 to 16 months (mean 6 months). After a single combined surgical procedure, closure of the macular hole was achieved in 32 of the 38 eyes (84%). Successful hole closure was defined as flattening of the edges of the hole with no evidence of subretinal fluid. In 29 of the 38 eyes (76%), vision improved (defined as two or more Snellen lines). In seven eyes (18%), there was no change and in two eyes (5%) vision decreased (Fig. 1). The intraoperative and postoperative complications are listed in Table 1. Of the six eyes (16%) in which the macular hole persisted after the initial surgery, only one eye was subjected to a second operation, which was unsuccessful. The remaining five eyes had a longstanding macular hole or agerelated macular degeneration (AMD) atrophies with negligible chances for VA improvement. Two eyes (5%) had posterior capsule rupture and in one of these eyes an IOL was inserted into the sulcus. Nine eyes (24%) required endolaser photocoagulation to peripheral retinal tears and in two of these, scleral buckling was added. Transient elevation of intraocular pressure (IOP) in eight eyes (2533 mmHg in six eyes and 38 43 mmHg in two eyes) was observed postoperatively and was managed with medication. In all cases, pressure returned to normal within the first 2 weeks after surgery without further intraocular complications. Posterior capsular opacification (PCO) developed in five eyes, three of which required Nd:YAG laser capsulotomy. In the
other two cases, opacification did not interfere with central vision. Total operating time for the combined procedure ranged from 70 to 200 min.
Discussion Miller et al. (1997) suggest that macular hole surgery and cataract extraction can be performed during the same operative session, with successful anatomical outcome and marked improvement in VA. Lahey et al. (2002) believe that, in addition to faster visual recovery, lens removal allows a more complete vitrectomy, including removal of the anterior vitreous without risking lens injury during vitrectomy. In our study, cataract surgery was performed in all eyes by limbal phacoemulsification prior to pars plana vitrectomy and posterior capsule IOL implantation. Placement of the IOL prior to the vitrectomy may hinder visualization of the posterior pole and peripheral retina because of a possibility of miosis or corneal striae; the edge of the lens may also cause unwanted light reflexes and optical changes (Ho et al. 1998). Immediate extraction of the lens prior to the pars plana vitrectomy facilitates the optical view of the posterior pole and the periphery and increases the safety of the posterior vitreous and ILM peeling (Benson et al. 1990). Additionally, because the incidence of retinal tears is relatively high in eyes undergoing macular hole surgery, cataract removal facilitates the scleral depression, which allows for better detection and treatment of small tears in the anterior retina. Cataract surgery in post-vitrectomized eyes presents higher risks because of the instability of Zinn’s zonules, possible damage to the posterior capsule during the previous vitrectomy, and an increased frequency of posterior capsular rupture without vitreous gel support. Another disadvantage in performing cataract extraction as a separate procedure following pars plana vitrectomy is that postoperative follow-up of a gas-filled eye is more difficult when a crystalline lens is in place. An aphakic state facilitates removal of the peripheral vitreous gel. The combined vitrectomy allows a better gas fill, which may provide a longer tamponade and improve hole closure rate (Thompson et al. 1996). It also allows entry site placement to be
173
ACTA OPHTHALMOLOGICA SCANDINAVICA 2005
Fig. 1. Comparisons of preoperative and postoperative visual acuities. Each number in the diagram refers to the number of eyes. Those above the diagonal line showed improved vision, those along the line had the same level of vision and those below the line had poorer vision. HM ¼ hand movements; LP ¼ light perception; CF ¼ counting fingers.
more anterior, reducing the risks of entry site complications. For the combined procedure, we believe that phacoemulsification offers many advantages compared to techniques such as extracapsular cataract extraction (ECCE) and pars plana lensectomy. A small, self-sealing, clear corneal incision prevents corneal distortion, ensures a watertight wound, reduces the development of postoperative astigmatism, and is a faster procedure than the large ECCE incision. Furthermore, a large corneoscleral incision may leak when IOP is elevated during vitrectomy (Blankenship et al. 1989) and corneal oedema may be more likely as a result of the longer manipulation and fluid
irrigation in the anterior segment (Batman et al. 2000). Phacoemulsification also has several advantages over lensectomy, such as faster nuclear removal, less frequent dislocation of the nuclear fragments into the vitreous and much easier removal of the peripheral lens cortex (Mackool 1989). During lensectomy, the IOL is not placed in the bag, but requires sulcus fixation that should be avoided whenever possible, as increased contact with the uveal tissue may result in postoperative inflammation. Finally, if the anterior capsule is left intact, there is a strong likelihood of lens epithelial proliferation. Making an anterior capsulotomy prevents proliferation but negates the benefit of the intact barrier between
Table 1. Intraoperative and postoperative complications. Complications
No. of eyes
%
Intraoperative Retinal tear Posterior capsule rupture Postoperative
9 2
23.6 5.3
Transient increased IOP Opacified posterior capsule Persistent macular hole
8 5 6
21 13.2 15.8
IOP ¼ intraocular pressure.
174
the anterior and posterior segments (Batman et al. 2000). Sheidow & Gonder (1998) reported the development of cystoid macular oedema in patients undergoing combined cataract and pars plana vitrectomy surgeries). In our study, the complication of clinical cystoid macular oedema was not observed. Pupillary capture has also been reported when phacoemulsification and IOL placement were combined with pars plana vitrectomy and intraocular tamponade (Rahman & Rosen 2002). This complication was avoided in our series by performing a smaller capsulorhexis, ensuring a strict facedown position, and securing wound closure. Although the incidence of PCO seems to be relatively low compared to the expected incidence after an ordinary phacoemulsification/IOL operation, the short follow-up period in this study does not permit safe conclusions about the incidence of PCO. In addition, studies indicate that PCO is very common (50%) after phacoemulsification in post-vitrectomized eyes, especially if gas is used at vitrectomy (Pinter & Sugar 1999). Transient elevations in IOP are relatively common complications during the early postoperative period, not only after combined macular hole surgery, but also after macular hole operation without lens extraction (Thompson et al. 1996) and other vitreoretinal procedures. Suggested mechanisms are obstruction of the trabecular meshwork by inflammatory debris or erythrocytes, a narrowing of the anterior chamber angle because of overfill of intraocular gas or oedema of the ciliary body, pre-existing undetected glaucoma or ocular hypertension, and residual viscoelastic in the anterior chamber. Suzuki et al. (2000) reported a slight myopic shift that occurs in eyes with simultaneous phacoemulsification and vitrectomy with gas tamponade, in which the IOL comes to rest slightly anteriorly to where it would have been without the gas bubble. They suggested that the predicted refraction before surgery and the actual refraction after surgery should be taken into consideration when calculating the lens power in these eyes. According to the literature, in macular holes of less than 12 months, ILM peeling, long-acting gas, and a 1-week, postoperative facedown position lead to an 88–98% success rate in anatomical closure
ACTA OPHTHALMOLOGICA SCANDINAVICA 2005 after one surgical procedure. Our success rate after one surgical procedure was 84%. Four of the six eyes with unsuccessful results had endured macular holes for more than 12 months. This latter group of patients has significantly lower success rates (70–80%) than those with recent-onset macular holes (Ryan & Gilbert 1994; Kwok et al. 2003). Finally, this study shows that the combined procedure is safe, may offer rapid visual rehabilitation, and may reduce treatment costs. Moreover, combined surgery decreases total operating time, preventing the potential problems associated with extra local or general anaesthesia. Patient preference for the combined procedure is encouraging because of the benefits of the combined treatment. We also believe that when both procedures, phacoemulsification and pars plana vitrectomy, are performed by the same surgeon, daily routine duties in a busy referral clinic are greatly facilitated. However, this condition requires the involvement of posterior segment surgeons who are highly skilled in the technique of phacoemulsification. We will continue to study the benefits and longterm results of this approach.
References Batman C, Cekic O, Totan Y, O¨zkan SS & Zilelioglu O (2000): Combined phacoemulsification, vitrectomy, foreign body extraction and intraocular lens implantation. J Cataract Refract Surg 26: 254–259.
Benson WE, Brown GC, Tasman W & McNamara JA (1990): Extracapsular cataract extraction, posterior chamber lens insertion, and pars plana vitrectomy in one operation. Ophthalmology 97: 918–921. Blankenship GW, Flynn HW & Kokarne GT (1989): Posterior chamber intraocular lens insertion during pars plana lensectomy and vitrectomy for complications of proliferative diabetic retinopathy. Am J Ophthalmol 108: 1–5. D’Amico DJ (1994): Vitreoretinal surgery principles and application. In: Albert DM & Jacobiec FA (eds). Principles and Practice of Ophthalmology. Vol. 2. Philadelphia: WB Saunders. 1133–1138. Ho AC, Guyer DR & Fine SL (1998): Macular hole. Surv Ophthalmol 42: 406–411. Kelly NE & Wendel RT (1991): Vitreous surgery for idiopathic macular holes: results of a pilot study. Arch Ophthalmol 109: 654–659. Kotecha AV, Sinclair SH, Gupta AK & Tipperman R (2000): Pars plana vitrectomy for macular holes combined with cataract extraction and lens implantation. J Cataract Refract Surg 31: 387–393. Kwok AK, Lai TY, Man-Chan W & Woo DC (2003): ICG-assisted retinal internal limiting membrane removal in stage 2 or 4 macular hole surgery. Br J Ophthalmol 87: 71–74. Lahey JM, Francis RP, Fong DS, Kearney JJ & Tanaka S (2002): Combining phacoemulsification with vitrectomy for treatment of macular holes. Br J Ophthalmol 86: 76–78. Leonard RE, Smiddy WE, Flynn HN Jr & Fewer W (1997): Longterm visual outcomes in patients with successful macular hole surgery. Ophthalmology 104: 1684–1752. Mackool RJ (1989): Pars plana vitrectomy and posterior chamber intraocular lens implantation in diabetic patients. [Letter.] Ophthalmology 96: 1679–1680. Miller JH, Googe JM & Hoskins JC (1997): Combined macular hole and cataract surgery. Am J Ophthalmol 123: 705–707.
Pinter SM & Sugar A (1999): Phacoemulsification in eyes with post pars plana vitrectomy: case control study. J Cataract Refract Surg 25: 556–561. Rahman R & Rosen PH (2002): Pupillary capture after combined management of cataract and vitreoretinal pathology. J Cataract Refract Surg 26: 1607–1612. Ryan EH Jr & Gilbert HD (1994): Results of surgical treatment of recent-onset fullthickness idiopathic macular holes. Arch Ophthalmol 112: 1545–1553. Sheidow TG & Gonder JR (1998): Cystoid macular oedema following combined phacoemulsification and vitrectomy for macular hole. Retina 18: 510–514. Suzuki Y, Sakuraba T, Mizutani H, Matsuhashi H & Nakazawa M (2000): Postoperative refractive error after simultaneous vitrectomy and cataract surgery. Ophthalmol Surg Lasers 31: 271–275. Thomson JT, Glaser BM, Sjaarda RN & Murphy RP (1995): Progression of nuclear sclerosis and longterm visual results of vitrectomy with transforming growth factor beta-2 for macular holes. Am J Ophthalmol 119: 48–54. Thomson JT, Smiddy WE, Glaser BM, Sjaarda RN & Flynn HW (1996): Intraocular tamponade duration and success of macular hole surgery. Retina 16: 373–382.
Received on December 16th, 2004. Accepted on October 18th, 2004. Correspondence: Ioannis Theocharis MD Department of Ophthalmology University Hospital of Uppsala 751 85 Uppsala Sweden Tel: þ 46 18 61 10 000 Fax: þ 46 18 51 06 30 Email:
[email protected]
175
