- Email: [email protected]
Combined phacoemulsification, foldable intraocular lens implantation, and 25-gauge transconjunctival sutureless vitrectomy
J CATARACT REFRACT SURG - VOL 32, MAY 2006
Combined phacoemulsification, foldable intraocular lens implantation, and 25-gauge transconjunctival sutureless vitrectomy Jong-uk Hwang, MD, Young Hee Yoon, MD, Deok-Soo Kim, MD, June-Gone Kim, MD
We describe a technique for combined cataract and vitreoretinal surgery using a 25-gauge transconjunctival sutureless vitrectomy system. This technique was successfully performed in 20 consecutive cases. Outcomes were assessed in terms of visual acuity, intraocular pressure, postoperative refractive error, and incidence of complications. The technical feasibility, rationale, and advantages and disadvantages of this technique are discussed. J Cataract Refract Surg 2006; 32:727–731 Q 2006 ASCRS and ESCRS
A visually significant cataract necessitating surgical intervention is frequently found in patients with various vitreoretinal diseases. Cataract often progresses postoperatively as a result of vitreoretinal surgery and use of intraocular gas or silicone oil.1 Removal of a cataract is necessary for safe performance of vitrectomy to get an adequate view and better access to the vitreous base, especially in the inferior quadrants during vitrectomy. Removal is also helpful for the fast visual rehabilitation after vitrectomy.2 Accordingly, cataract extraction using an extracapsular cataract extraction or phacoemulsification technique combined with pars plana vitrectomy has been reported as a safe and effective surgical option for coexisting cataract and vitreoretinal pathologies.2–4 Recently, 25-gauge transconjunctival sutureless vitrectomy (TSV25) was introduced as a minimally invasive vitrectomy procedure.5,6 Herein, we describe a technique for combined cataract and vitreoretinal surgery using the TSV25 system and results of a consecutive series of 20 eyes of 20 patients in whom this technique was applied.
Accepted for publication September 15, 2005. From the Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. No author has a financial or proprietary interest in any material or method mentioned. Reprint requests to June-Gone Kim, MD, Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine #388-1, Pungnap-Dong, Songpa-Gu, Seoul 138-736, Korea. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
SURGICAL TECHNIQUE
A retrobulbar block or general endotracheal anesthesia is given. Cataract extraction precedes vitreoretinal surgery using the TSV system (Millennium Microsurgical System, Bausch & Lomb). However, an expected difficulty is the problem of inserting an infusion cannula after the cataract extraction because of reduced globe resistance and instability of the cataract wound. Therefore, a transconjunctival trocar cannula is inserted inferotemporally, 3.0 mm from the limbus, before the cataract extraction procedure. The trocar is removed, and an infusion line is connected into the cannula. The infusion line is kept closed after connection throughout cataract surgery. For incision construction, a clear corneal tunnel or scleral tunnel technique can be used. A 2.75 mm wide and 1.5 to 2.0 mm long incision is created at 11 o’clock with an ophthalmic slit knife (Alcon Laboratories, Inc.). A 5.0 to 6.0 mm diameter curvilinear capsulorhexis is made using a 26-gauge disposable cystotome needle. Bimanual phacoemulsification using the stop-and-chop technique and cortex removal are performed using the WhiteStar system–loaded AMO Sovereign unit (Advanced Medical Optics, Inc.). The anterior chamber and capsular bag are filled with sodium hyaluronate 1% (Healon), and the incision is extended to approximately a 3.5 mm width with an ophthalmic slit knife for intraocular lens (IOL) insertion. An AcrySof MA60BM IOL (Alcon Laboratories, Inc.) with an optic diameter of 6.0 mm is inserted in the capsular bag using a Monarch II IOL delivery system (Alcon Laboratories, Inc.) or a manual folding technique. Residual viscoelastic agent is removed using an irrigation/aspiration device in the Sovereign unit. The integrity of the sclerocorneal or clear corneal tunnel is assessed. 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2006.01.061
727
TECHNIQUES: COMBINED CATARACT AND VITREORETINAL SURGERY
Table 1. Details of 20 consecutive patients who had combined phacoemulsification, foldable IOL implantation, and 25-gauge TSV25.
Age (Y)/Sex 69/F 65/M 66/F 42/F 63/F 68/M 73/M 57/M 46/M 62/M 57/F 68/M 43/F 70/F 62/M 59/F 67/M 54/F 48/F 40/M
Diagnosis
Operative Procedures
Type of Anesthesia
Type of Incision
Operation Time (min)
Preoperative Visual Acuity/ Visual acuity at 1 day/ Visual acuity at 1 week/ Visual acuity at 1 month/ Visual acuity at 3 months
CAT C ERM CAT C ERM CAT C ERM CAT C DMVH CAT C Diabetic vitreous opacity CAT C Diabetic macular edema CAT C ERM CAT C DMVH CAT C DMVH C TRD CAT C DMVH CAT C DMVH CAT C ERM CAT C Uveitic vitreous opacity CAT C DMVH CAT C DMVH CAT C DMVH CAT C DMVH
Phaco PCIOL PPV MP Phaco PCIOL PPV MP Phaco PCIOL PPV MP Phaco PCIOL PPV MP EL Phaco PCIOL PPV EL
GA RB RB GA RB
ST ST CC ST ST
52 50 65 62 65
0.10/0.02/0.05/0.05/0.16 0.4/0.3/0.5/0.63/0.63 0.2/CF/0.03/0.05/0.05 CF/CF/0.125/0.05/0.20 0.03/0.04/0.125/0.16/0.20
Phaco PCIOL PPV MP EL
RB
ST
68
0.16/0.05/0.10/0.125/0.20
Phaco PCIOL PPV MP Phaco PCIOL PPV EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP ILMP Phaco PCIOL PPV MP IVK
RB RB RB GA GA GA RB
ST ST ST CC CC ST CC
54 63 63 80 73 56 30
0.2/0.10/0.10/0.25/0.80 0.25/0.08/0.16/0.4/0.50 0.25/0.04/0.16/0.2/0.50 0.05/0.15/0.32/0.4/0.63 CF/0.10/0.10/0.32/0.32 0.4/0.05/0.10/0.2/0.32 0.07/0.10/0.32/0.32/0.50
Phaco PCIOL PPV PPL MP EL Phaco PCIOL PPV EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP EL
GA RB RB GA
CC ST ST CC
113 57 62 112
0.03/CF/0.05/0.07/0.50 0.2/0.15/0.50/0.80/0.80 0.4/0.1/0.07/0.20/0.32 0.05/CF/HM/0.25/0.07
CAT C Diabetic macular edema CAT C DMVH CAT C DMVH
Phaco PCIOL PPV MP EL IVK
RB
ST
80
0.05/0.02/0.16/0.16/0.16
Phaco PCIOL PPV EL Phaco PCIOL PPV MP EL
RB GA
ST CC
70 95
0.04/CF/0.05/0.20/0.25 0.16/HM/HM/0.25/0.25
CAT Z cataract; CC Z clear corneal; CF Z counting fingers; DMVH Z diabetic vitreous hemorrhage; EL Z endolaser photocoagulation; ERM Z epiretinal membrane; GA Z general anesthesia; HM Z hand motion; IVK Z intravitreal triamcinolone acetonide injection; MP Z membrane peeling; MR Z manifest refraction; PC Z posterior capsule; PCIOL Z Posterior chamber intraocular lens implantation; Phaco Z phacoemulsification; RB Z retrobulbar block; SE Z spherical equivalent; ST Z scleral tunnel; TRD Z tractional retinal detachment
An infusion line is started to acquire an appropriate resisting pressure. Transconjunctival insertion of cannulas using a beveled trocar is performed superotemporally and superonasally, 3.0 mm apart from the limbus. Cannulas are temporarily closed with plugs. A silicone ring (Hoya Corp.), which does not require sutures for positioning, is placed on the eye to help position the vitrectomy lens. A standard vitrectomy lens (DORC) is placed after an appropriate amount of hypromellose is administered (Methocel 2%). After the plugs are removed, core vitrectomy using a 25-gauge high-speed vitreous cutter is performed. When suction force of TSV25 is not sufficient to create posterior vitreous detachment, it can be created mechanically using a 25-gauge flexible-extendable pick. In eyes with an idiopathic epiretinal membrane, meticulous membrane peeling using 25-gauge horizontal microscissors and a microforceps is performed. Eyes with diabetic vitreous hemorrhage
728
necessitate vitrectomy and peeling of the posterior hyaloid. Cutting the vitreous base is performed with a scleral depression technique. Endolaser photocoagulation using a 25-gauge laser probe is performed in all cases of diabetic vitreous hemorrhage. The surgery is completed by removal of the entrysite alignment cannulas without scleral or conjunctival suturing. The infusion line and cannula are removed simultaneously. The conjunctiva above the sclerotomy is displaced to prevent direct connection between the 2 entry sites. Intravitreal triamcinolone acetonide (4 mg/0.1 mL) is injected as an adjuvant after the combined cataract and vitreoretinal surgery is completed in patients with vitreous opacity due to previous uveitis and persistent diabetic macular edema. The patients are educated about keeping a semi-Fowler’s position for 1 day to prevent
J CATARACT REFRACT SURG - VOL 32, MAY 2006
TECHNIQUES: COMBINED CATARACT AND VITREORETINAL SURGERY
Table 1 (cont.)
Preoperative IOP (mm Hg)/ IOP at 1 day/ IOP at 1 week/ IOP at 1 month/ IOP at 3 months
Axial Length (mm)
Desired Refraction (D)
16/20/14/14/15 18/18/21/16/16 9/13/9/10/11 12/16/7/8/19 13/15/13/12/14
23.8 24.29 22.12 24.2 22.73
ÿ0.20 ÿ0.38 ÿ0.42 ÿ0.61 ÿ0.52
ÿ0.25 ÿ0.375 ÿ1.25 0.75
No No No No No
12/19/13/10/12
23.53
ÿ0.59
ÿ0.25
No
15/19/12/13/15 12/10/16/12/13 15/21/14/13/15 11/22/13/9/8 14/10/10/15/12 15/18/15/15/14 24/10/30/14/14
23.81 23.75 23.29 22.87 23.5 23.5 21.46
ÿ0.25 ÿ0.63 ÿ2.42 ÿ0.67 ÿ0.79 ÿ0.12 ÿ0.52
0.00 ÿ0.25 ÿ2.125
No PC tear No No Rebleeding (at 5 months) No No
15/23/18/15/13 12/4/18/12/12 14/9/11/11/9 13/36/4/4/8
22.91 22.6 21.73 23.92
ÿ0.47 ÿ0.46 ÿ0.30 ÿ0.40
ÿ1.25
20/17/18/19/22
22.44
ÿ0.10
0.00
15/18/10/12/10 17/33/19/16/16
23.59 22.97
ÿ0.26 ÿ0.31
ÿ0.25
the triamcinolone acetonide from veiling the macular area. RESULTS
All patients had a follow-up of at least 3 months. Details regarding the patients are listed in Table 1. The mean preoperative visual acuity was 0.795 logMAR G 0.329 (SD). The mean postoperative visual acuity was 1.072 G 0.420 logMAR, 0.840 G 0.436 logMAR, 0.601 G 0.206 logMAR, and 0.482 G 0.218 logMAR at 1 day, 1 week, 1 month, and 3 months, respectively. A paired t test revealed a statistically significant improvement in visual acuity at 1 month (P Z .019) and 3 months (P Z .001) postoperatively. The mean preoperative intraocular pressure (IOP) was 14.60 G 3.36 mm Hg. The mean postoperative IOP was
Postoperative SE of MR (D)
ÿ0.75
0.125
Complications
PC tear No No CB detach (intraoperative), Rebleeding (at 2 months) No No Hyphema
17.55 G 7.64 mm Hg, 14.05 G 5.72 mm Hg, 12.58 G 3.41 mm Hg, 13.45 G 3.47 mm Hg at 1 day, 1 week, 1 month, and 3 months, respectively. One patient presented with a low IOP (4 mm Hg) on postoperative day 1; however, the pressure spontaneously recovered to 18 mm Hg 1 month postoperatively. Manifest refraction was performed in 13 eyes. In these eyes, the mean preoperative desired refraction by IOL power calculation was ÿ0.582 G 0.587 diopters (D). The mean postoperative spherical equivalent value by manifest refraction was ÿ0.452 G 737 D. According to the results of regression analysis, preoperative desired refraction and postoperative refractive error were strongly correlated (Pearson correlation coefficient r Z .735). As an intraoperative complication, posterior capsule tear occurred in 2 eyes. The visualization of the posterior segment was not reduced significantly by the hydration of
J CATARACT REFRACT SURG - VOL 32, MAY 2006
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TECHNIQUES: COMBINED CATARACT AND VITREORETINAL SURGERY
the corneal tunnel. Hyphema was observed in 1 eye, and partial detachment of the ciliary body was observed in 1 eye. No anterior segment neovascularization was observed in any patient during the follow-up period. Clinically significant posterior capsule opacification was also not observed during the follow-up period, and no complications associated with intravitreal triamcinolone acetonide injection were detected.
DISCUSSION
The TSV system was developed as a minimally invasive approach for patients who require vitrectomy for vitreoretinal pathology, 5,6 and the system has expanded beyond the traditional indications of pars plana vitrectomy.7,8 In the past 10 years, the use of tunnel-based sclerotomy incisions, originally described by Chen,9 has been suggested for the creation of self-sealing incisions in vitreoretinal surgery. However, a conjunctival peritomy and suturing were required in these approaches and many complications associated with sclerotomy incisions have been reported.9–12 The TSV system resolved these sclerotomy-related problems by introducing new 25-gauge entry-site cannulas and new vitrectomy instruments.5,6 Considering the advantages of the TSV system, office-based combined cataract and vitreoretinal surgery using the TSV is expected to play an important role as a minimally invasive combined procedure. A sclerocorneal tunnel produces less corneal tissue trauma and better wound integrity, which is important for subsequent vitreoretinal procedures.13 Regarding the minimal invasiveness of TSV, however, clear corneal incision is a more rational approach because it does not necessitate conjunctival peritomy or suturing for wound closure. In this situation, no suture is needed during the entire combined cataract and vitreoretinal surgery. To make this possible, during incision construction, the corneal tunnel should be long enough for strengthening the integrity of the wound. Mackool14 and Scharwey et al.2 followed the phacoemulsification–vitrectomy–IOL insertion sequence in their reports of combined cataract and vitreoretinal surgery using 20-gauge conventional pars plana vitrectomy. They filled the anterior chamber with a viscoelastic agent during vitreoretinal surgery and performed suturing for strengthening wound tightness before initiating vitrectomy. With viscoelastic agents, especially with nonhomogenous ones in the anterior chamber, visualization of the macula under high magnification might be suboptimal.13 In our experience, IOL insertion does not need to be delayed until completion of vitreoretinal surgery. The worrisome ‘‘image jump’’ phenomenon or prismatic effect caused by the IOL
730
edge (that is supposed to disturb the visualization of the retinal far periphery) did not cause visualization problems during vitrectomy. Contrary to many advantages of the TSV system, the smaller port and diameter of the 25-gauge vitreous cutter cause diminution of cutting and aspiration rates.5,6 In a reduced aspiration rate, occlusion of outflow with aspirated material might occur. In fact, on the basis of these limitations, the efficiency of the TSV system could be somewhat limited in patients with dense fibrous proliferation.6 Our 20 cases did not include examples of these cases, such as extensive fibrovascular proliferation in proliferative diabetic retinopathy and retinal detachment accompanying severe proliferative vitreoretinopathy. In addition, because we did not have cases that needed intraocular gas, air, or silicone tamponade, further investigation is needed for clarifying the effectiveness and safety of combined cataract and vitreoretinal surgery accompanied with intraocular tamponade. Nevertheless, considering the original purpose of the TSV system, it is questionable whether the matter of minimal invasiveness is still meaningful in cases with severe vitreoretinal pathologies requiring intraocular tamponade. In conclusion, we consider this minimally invasive approach a desirable and effective method for combined surgery in selected patients with combined cataract and vitreoretinal pathology. However, because this is a noncomparative study, further studies are needed to clarify the superior outcome of this technique compared with other combined surgery techniques.
REFERENCES 1. Faulborn J, Conway BP, Machemer R. Surgical complications of pars plana vitreous surgery. Ophthalmology 1978; 85:116–125 2. Scharwey K, Pavlovic S, Jacobi KW. Combined clear corneal phacoemulsification, vitreoretinal surgery, and intraocular lens implantation. J Cataract Refract Surg 1999; 25:693–698 3. Benson WE, Brown GC, Tasman W, McNamara JA. Extracapsular cataract extraction, posterior chamber lens insertion, and pars plana vitrectomy in one operation. Ophthalmology 1990; 97:918–921 4. Koenig SB, Mieler WF, Han DP, Abrams GW. Combined phacoemulsification, pars plana vitrectomy, and posterior chamber intraocular lens insertion. Arch Ophthalmol 1992; 110:1101–1104 5. Fujii GY, de Juan E Jr, Humayun MS, et al. A new 25 G instrument system for transconjunctival sutureless vitrectomy surgery. Ophthalmology 2002; 109:1807–1812; discussion, 1813 6. Fujii GY, de Juan E Jr, Humayun MS, et al. Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002; 109:1814–1820 7. Chalam KV, Shah VA. Successful management of cataract surgery associated with vitreous loss with sutureless small-gauge pars plana vitrectomy. Am J Ophthalmol 2004; 138:79–84 8. Lee HK, Kim CY, Kwon OW, et al. Removal of dense posterior capsule opacification after congenital cataract extraction using the transconjunctival sutureless vitrectomy system. J Cataract Refract Surg 2004; 30:1626–1628
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9. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol 1996; 114:1273–1275 10. Yeshurun I, Rock T, Bartov E. Modified sutureless sclerotomies for pars plana vitrectomy. Am J Ophthalmol 2004; 138:866–867 11. Theelen T, Verbeek AM, Tilanus MAD, van den Biesen PR. A novel technique for self-sealing, wedge-shaped pars plana sclerotomies and its features in ultrasound biomicroscopy and clinical outcome. Am J Ophthalmol 2003; 136:1085–1092
12. Kwok AKH, Tham CYC, Lam DSC, et al. Modified sutureless sclerotomies in pars plana vitrectomy. Am J Ophthalmol 1999; 127:731–733 13. Lam DSC, Young AL, Rao SK, et al. Combined phacoemulsification, pars plana vitrectomy, and foldable intraocular lens implantation. J Cataract Refract Surg 2003; 29:1064–1069 14. Mackool RJ. Pars plana vitrectomy and posterior chamber intraocular lens implantation in diabetic patients [letter]. Ophthalmology 1989; 96:1679–1680
J CATARACT REFRACT SURG - VOL 32, MAY 2006
731
Combined phacoemulsification, foldable intraocular lens implantation, and 25-gauge transconjunctival sutureless vitrectomy Jong-uk Hwang, MD, Young Hee Yoon, MD, Deok-Soo Kim, MD, June-Gone Kim, MD
We describe a technique for combined cataract and vitreoretinal surgery using a 25-gauge transconjunctival sutureless vitrectomy system. This technique was successfully performed in 20 consecutive cases. Outcomes were assessed in terms of visual acuity, intraocular pressure, postoperative refractive error, and incidence of complications. The technical feasibility, rationale, and advantages and disadvantages of this technique are discussed. J Cataract Refract Surg 2006; 32:727–731 Q 2006 ASCRS and ESCRS
A visually significant cataract necessitating surgical intervention is frequently found in patients with various vitreoretinal diseases. Cataract often progresses postoperatively as a result of vitreoretinal surgery and use of intraocular gas or silicone oil.1 Removal of a cataract is necessary for safe performance of vitrectomy to get an adequate view and better access to the vitreous base, especially in the inferior quadrants during vitrectomy. Removal is also helpful for the fast visual rehabilitation after vitrectomy.2 Accordingly, cataract extraction using an extracapsular cataract extraction or phacoemulsification technique combined with pars plana vitrectomy has been reported as a safe and effective surgical option for coexisting cataract and vitreoretinal pathologies.2–4 Recently, 25-gauge transconjunctival sutureless vitrectomy (TSV25) was introduced as a minimally invasive vitrectomy procedure.5,6 Herein, we describe a technique for combined cataract and vitreoretinal surgery using the TSV25 system and results of a consecutive series of 20 eyes of 20 patients in whom this technique was applied.
Accepted for publication September 15, 2005. From the Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. No author has a financial or proprietary interest in any material or method mentioned. Reprint requests to June-Gone Kim, MD, Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine #388-1, Pungnap-Dong, Songpa-Gu, Seoul 138-736, Korea. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
SURGICAL TECHNIQUE
A retrobulbar block or general endotracheal anesthesia is given. Cataract extraction precedes vitreoretinal surgery using the TSV system (Millennium Microsurgical System, Bausch & Lomb). However, an expected difficulty is the problem of inserting an infusion cannula after the cataract extraction because of reduced globe resistance and instability of the cataract wound. Therefore, a transconjunctival trocar cannula is inserted inferotemporally, 3.0 mm from the limbus, before the cataract extraction procedure. The trocar is removed, and an infusion line is connected into the cannula. The infusion line is kept closed after connection throughout cataract surgery. For incision construction, a clear corneal tunnel or scleral tunnel technique can be used. A 2.75 mm wide and 1.5 to 2.0 mm long incision is created at 11 o’clock with an ophthalmic slit knife (Alcon Laboratories, Inc.). A 5.0 to 6.0 mm diameter curvilinear capsulorhexis is made using a 26-gauge disposable cystotome needle. Bimanual phacoemulsification using the stop-and-chop technique and cortex removal are performed using the WhiteStar system–loaded AMO Sovereign unit (Advanced Medical Optics, Inc.). The anterior chamber and capsular bag are filled with sodium hyaluronate 1% (Healon), and the incision is extended to approximately a 3.5 mm width with an ophthalmic slit knife for intraocular lens (IOL) insertion. An AcrySof MA60BM IOL (Alcon Laboratories, Inc.) with an optic diameter of 6.0 mm is inserted in the capsular bag using a Monarch II IOL delivery system (Alcon Laboratories, Inc.) or a manual folding technique. Residual viscoelastic agent is removed using an irrigation/aspiration device in the Sovereign unit. The integrity of the sclerocorneal or clear corneal tunnel is assessed. 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2006.01.061
727
TECHNIQUES: COMBINED CATARACT AND VITREORETINAL SURGERY
Table 1. Details of 20 consecutive patients who had combined phacoemulsification, foldable IOL implantation, and 25-gauge TSV25.
Age (Y)/Sex 69/F 65/M 66/F 42/F 63/F 68/M 73/M 57/M 46/M 62/M 57/F 68/M 43/F 70/F 62/M 59/F 67/M 54/F 48/F 40/M
Diagnosis
Operative Procedures
Type of Anesthesia
Type of Incision
Operation Time (min)
Preoperative Visual Acuity/ Visual acuity at 1 day/ Visual acuity at 1 week/ Visual acuity at 1 month/ Visual acuity at 3 months
CAT C ERM CAT C ERM CAT C ERM CAT C DMVH CAT C Diabetic vitreous opacity CAT C Diabetic macular edema CAT C ERM CAT C DMVH CAT C DMVH C TRD CAT C DMVH CAT C DMVH CAT C ERM CAT C Uveitic vitreous opacity CAT C DMVH CAT C DMVH CAT C DMVH CAT C DMVH
Phaco PCIOL PPV MP Phaco PCIOL PPV MP Phaco PCIOL PPV MP Phaco PCIOL PPV MP EL Phaco PCIOL PPV EL
GA RB RB GA RB
ST ST CC ST ST
52 50 65 62 65
0.10/0.02/0.05/0.05/0.16 0.4/0.3/0.5/0.63/0.63 0.2/CF/0.03/0.05/0.05 CF/CF/0.125/0.05/0.20 0.03/0.04/0.125/0.16/0.20
Phaco PCIOL PPV MP EL
RB
ST
68
0.16/0.05/0.10/0.125/0.20
Phaco PCIOL PPV MP Phaco PCIOL PPV EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP ILMP Phaco PCIOL PPV MP IVK
RB RB RB GA GA GA RB
ST ST ST CC CC ST CC
54 63 63 80 73 56 30
0.2/0.10/0.10/0.25/0.80 0.25/0.08/0.16/0.4/0.50 0.25/0.04/0.16/0.2/0.50 0.05/0.15/0.32/0.4/0.63 CF/0.10/0.10/0.32/0.32 0.4/0.05/0.10/0.2/0.32 0.07/0.10/0.32/0.32/0.50
Phaco PCIOL PPV PPL MP EL Phaco PCIOL PPV EL Phaco PCIOL PPV MP EL Phaco PCIOL PPV MP EL
GA RB RB GA
CC ST ST CC
113 57 62 112
0.03/CF/0.05/0.07/0.50 0.2/0.15/0.50/0.80/0.80 0.4/0.1/0.07/0.20/0.32 0.05/CF/HM/0.25/0.07
CAT C Diabetic macular edema CAT C DMVH CAT C DMVH
Phaco PCIOL PPV MP EL IVK
RB
ST
80
0.05/0.02/0.16/0.16/0.16
Phaco PCIOL PPV EL Phaco PCIOL PPV MP EL
RB GA
ST CC
70 95
0.04/CF/0.05/0.20/0.25 0.16/HM/HM/0.25/0.25
CAT Z cataract; CC Z clear corneal; CF Z counting fingers; DMVH Z diabetic vitreous hemorrhage; EL Z endolaser photocoagulation; ERM Z epiretinal membrane; GA Z general anesthesia; HM Z hand motion; IVK Z intravitreal triamcinolone acetonide injection; MP Z membrane peeling; MR Z manifest refraction; PC Z posterior capsule; PCIOL Z Posterior chamber intraocular lens implantation; Phaco Z phacoemulsification; RB Z retrobulbar block; SE Z spherical equivalent; ST Z scleral tunnel; TRD Z tractional retinal detachment
An infusion line is started to acquire an appropriate resisting pressure. Transconjunctival insertion of cannulas using a beveled trocar is performed superotemporally and superonasally, 3.0 mm apart from the limbus. Cannulas are temporarily closed with plugs. A silicone ring (Hoya Corp.), which does not require sutures for positioning, is placed on the eye to help position the vitrectomy lens. A standard vitrectomy lens (DORC) is placed after an appropriate amount of hypromellose is administered (Methocel 2%). After the plugs are removed, core vitrectomy using a 25-gauge high-speed vitreous cutter is performed. When suction force of TSV25 is not sufficient to create posterior vitreous detachment, it can be created mechanically using a 25-gauge flexible-extendable pick. In eyes with an idiopathic epiretinal membrane, meticulous membrane peeling using 25-gauge horizontal microscissors and a microforceps is performed. Eyes with diabetic vitreous hemorrhage
728
necessitate vitrectomy and peeling of the posterior hyaloid. Cutting the vitreous base is performed with a scleral depression technique. Endolaser photocoagulation using a 25-gauge laser probe is performed in all cases of diabetic vitreous hemorrhage. The surgery is completed by removal of the entrysite alignment cannulas without scleral or conjunctival suturing. The infusion line and cannula are removed simultaneously. The conjunctiva above the sclerotomy is displaced to prevent direct connection between the 2 entry sites. Intravitreal triamcinolone acetonide (4 mg/0.1 mL) is injected as an adjuvant after the combined cataract and vitreoretinal surgery is completed in patients with vitreous opacity due to previous uveitis and persistent diabetic macular edema. The patients are educated about keeping a semi-Fowler’s position for 1 day to prevent
J CATARACT REFRACT SURG - VOL 32, MAY 2006
TECHNIQUES: COMBINED CATARACT AND VITREORETINAL SURGERY
Table 1 (cont.)
Preoperative IOP (mm Hg)/ IOP at 1 day/ IOP at 1 week/ IOP at 1 month/ IOP at 3 months
Axial Length (mm)
Desired Refraction (D)
16/20/14/14/15 18/18/21/16/16 9/13/9/10/11 12/16/7/8/19 13/15/13/12/14
23.8 24.29 22.12 24.2 22.73
ÿ0.20 ÿ0.38 ÿ0.42 ÿ0.61 ÿ0.52
ÿ0.25 ÿ0.375 ÿ1.25 0.75
No No No No No
12/19/13/10/12
23.53
ÿ0.59
ÿ0.25
No
15/19/12/13/15 12/10/16/12/13 15/21/14/13/15 11/22/13/9/8 14/10/10/15/12 15/18/15/15/14 24/10/30/14/14
23.81 23.75 23.29 22.87 23.5 23.5 21.46
ÿ0.25 ÿ0.63 ÿ2.42 ÿ0.67 ÿ0.79 ÿ0.12 ÿ0.52
0.00 ÿ0.25 ÿ2.125
No PC tear No No Rebleeding (at 5 months) No No
15/23/18/15/13 12/4/18/12/12 14/9/11/11/9 13/36/4/4/8
22.91 22.6 21.73 23.92
ÿ0.47 ÿ0.46 ÿ0.30 ÿ0.40
ÿ1.25
20/17/18/19/22
22.44
ÿ0.10
0.00
15/18/10/12/10 17/33/19/16/16
23.59 22.97
ÿ0.26 ÿ0.31
ÿ0.25
the triamcinolone acetonide from veiling the macular area. RESULTS
All patients had a follow-up of at least 3 months. Details regarding the patients are listed in Table 1. The mean preoperative visual acuity was 0.795 logMAR G 0.329 (SD). The mean postoperative visual acuity was 1.072 G 0.420 logMAR, 0.840 G 0.436 logMAR, 0.601 G 0.206 logMAR, and 0.482 G 0.218 logMAR at 1 day, 1 week, 1 month, and 3 months, respectively. A paired t test revealed a statistically significant improvement in visual acuity at 1 month (P Z .019) and 3 months (P Z .001) postoperatively. The mean preoperative intraocular pressure (IOP) was 14.60 G 3.36 mm Hg. The mean postoperative IOP was
Postoperative SE of MR (D)
ÿ0.75
0.125
Complications
PC tear No No CB detach (intraoperative), Rebleeding (at 2 months) No No Hyphema
17.55 G 7.64 mm Hg, 14.05 G 5.72 mm Hg, 12.58 G 3.41 mm Hg, 13.45 G 3.47 mm Hg at 1 day, 1 week, 1 month, and 3 months, respectively. One patient presented with a low IOP (4 mm Hg) on postoperative day 1; however, the pressure spontaneously recovered to 18 mm Hg 1 month postoperatively. Manifest refraction was performed in 13 eyes. In these eyes, the mean preoperative desired refraction by IOL power calculation was ÿ0.582 G 0.587 diopters (D). The mean postoperative spherical equivalent value by manifest refraction was ÿ0.452 G 737 D. According to the results of regression analysis, preoperative desired refraction and postoperative refractive error were strongly correlated (Pearson correlation coefficient r Z .735). As an intraoperative complication, posterior capsule tear occurred in 2 eyes. The visualization of the posterior segment was not reduced significantly by the hydration of
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the corneal tunnel. Hyphema was observed in 1 eye, and partial detachment of the ciliary body was observed in 1 eye. No anterior segment neovascularization was observed in any patient during the follow-up period. Clinically significant posterior capsule opacification was also not observed during the follow-up period, and no complications associated with intravitreal triamcinolone acetonide injection were detected.
DISCUSSION
The TSV system was developed as a minimally invasive approach for patients who require vitrectomy for vitreoretinal pathology, 5,6 and the system has expanded beyond the traditional indications of pars plana vitrectomy.7,8 In the past 10 years, the use of tunnel-based sclerotomy incisions, originally described by Chen,9 has been suggested for the creation of self-sealing incisions in vitreoretinal surgery. However, a conjunctival peritomy and suturing were required in these approaches and many complications associated with sclerotomy incisions have been reported.9–12 The TSV system resolved these sclerotomy-related problems by introducing new 25-gauge entry-site cannulas and new vitrectomy instruments.5,6 Considering the advantages of the TSV system, office-based combined cataract and vitreoretinal surgery using the TSV is expected to play an important role as a minimally invasive combined procedure. A sclerocorneal tunnel produces less corneal tissue trauma and better wound integrity, which is important for subsequent vitreoretinal procedures.13 Regarding the minimal invasiveness of TSV, however, clear corneal incision is a more rational approach because it does not necessitate conjunctival peritomy or suturing for wound closure. In this situation, no suture is needed during the entire combined cataract and vitreoretinal surgery. To make this possible, during incision construction, the corneal tunnel should be long enough for strengthening the integrity of the wound. Mackool14 and Scharwey et al.2 followed the phacoemulsification–vitrectomy–IOL insertion sequence in their reports of combined cataract and vitreoretinal surgery using 20-gauge conventional pars plana vitrectomy. They filled the anterior chamber with a viscoelastic agent during vitreoretinal surgery and performed suturing for strengthening wound tightness before initiating vitrectomy. With viscoelastic agents, especially with nonhomogenous ones in the anterior chamber, visualization of the macula under high magnification might be suboptimal.13 In our experience, IOL insertion does not need to be delayed until completion of vitreoretinal surgery. The worrisome ‘‘image jump’’ phenomenon or prismatic effect caused by the IOL
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edge (that is supposed to disturb the visualization of the retinal far periphery) did not cause visualization problems during vitrectomy. Contrary to many advantages of the TSV system, the smaller port and diameter of the 25-gauge vitreous cutter cause diminution of cutting and aspiration rates.5,6 In a reduced aspiration rate, occlusion of outflow with aspirated material might occur. In fact, on the basis of these limitations, the efficiency of the TSV system could be somewhat limited in patients with dense fibrous proliferation.6 Our 20 cases did not include examples of these cases, such as extensive fibrovascular proliferation in proliferative diabetic retinopathy and retinal detachment accompanying severe proliferative vitreoretinopathy. In addition, because we did not have cases that needed intraocular gas, air, or silicone tamponade, further investigation is needed for clarifying the effectiveness and safety of combined cataract and vitreoretinal surgery accompanied with intraocular tamponade. Nevertheless, considering the original purpose of the TSV system, it is questionable whether the matter of minimal invasiveness is still meaningful in cases with severe vitreoretinal pathologies requiring intraocular tamponade. In conclusion, we consider this minimally invasive approach a desirable and effective method for combined surgery in selected patients with combined cataract and vitreoretinal pathology. However, because this is a noncomparative study, further studies are needed to clarify the superior outcome of this technique compared with other combined surgery techniques.
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9. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol 1996; 114:1273–1275 10. Yeshurun I, Rock T, Bartov E. Modified sutureless sclerotomies for pars plana vitrectomy. Am J Ophthalmol 2004; 138:866–867 11. Theelen T, Verbeek AM, Tilanus MAD, van den Biesen PR. A novel technique for self-sealing, wedge-shaped pars plana sclerotomies and its features in ultrasound biomicroscopy and clinical outcome. Am J Ophthalmol 2003; 136:1085–1092
12. Kwok AKH, Tham CYC, Lam DSC, et al. Modified sutureless sclerotomies in pars plana vitrectomy. Am J Ophthalmol 1999; 127:731–733 13. Lam DSC, Young AL, Rao SK, et al. Combined phacoemulsification, pars plana vitrectomy, and foldable intraocular lens implantation. J Cataract Refract Surg 2003; 29:1064–1069 14. Mackool RJ. Pars plana vitrectomy and posterior chamber intraocular lens implantation in diabetic patients [letter]. Ophthalmology 1989; 96:1679–1680
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