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Gas sandwich technique for IOL support in combined cataract and vitreoretinal surgery
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Gas Sandwich Technique for IOL Support in Combined Cataract and Vitreoretinal Surgery
C
ombined surgical procedures involving the anterior and posterior segments of the eye are becoming more important. While vitrectomy and subsequent retinal maneuvers are often necessary to treat cases of severe retinal diseases, the population of patients requiring such interventions is growing older. In many cases, it is desirable to perform cataract surgery at the same time. The frequently used surgical armament of vitreoretinal surgeons includes tamponades of the vitreous cavity with air, longer acting gas tamponades, and silicone oil. The intraocular lens (IOL), preferably located inside the capsular bag, is an appropriate barrier for eyes filled with silicone oil. Tamponades composed of air or an expandable gas such as sulfur hexafluoride or perfluoropropane exert forces on the lens–iris diaphragm anteriorly, flattening the anterior chamber and possibly obstructing the anterior chamber angle. This may lead to anterior dislocation of the IOL and instability of the diaphragm. We operated on a 61-year-old white man with diabetes mellitus for more than 30 years who had recurrent vitreous hemorrhages in his left eye. Under general anesthesia, surgery began with phacoemulsification of the lens. The capsulorhexis was difficult because of the lack of a red fundus reflex. A foldable IOL (AcrySof威, Alcon
Pharma) with a power of 25.0 diopters was placed in the capsular bag. A standard 3-port pars plana vitrectomy was performed, which included removal of the vitreous hemorrhage and panretinal laser photocoagulation. To reduce the risk of recurrent hemorrhages in the early postoperative period, a fluid–air exchange was performed. The air pressure setting on the vitrectomy machine was 45 mm Hg. While this procedure was being done, it was noted that the anterior chamber flattened and the IOL came close to the posterior surface of the cornea. Then, air was injected into the anterior chamber to increase its volume, stabilize the lens–iris diaphragm, and keep the IOL safely positioned inside the capsular bag. In this case, gas tamponade in the posterior segment of the globe and simultaneously in the anterior chamber helped to stabilize the IOL in the early postoperative period. The danger of IOL dislocation was present in this patient because the capsulorhexis was large and not well centered. Subsequent to a poor fundus reflex, irregularities of the capsulorhexis are to be expected or may be more frequent in eyes with retinal pathology and visually disturbing cataracts. Complications reported following combined vitrectomy and phacoemulsification include fibrin reaction, posterior synechia, hyphema, and others.1,2 A recent study investigated the preoperative and postoperative refraction in combined cases in which gas tamponade of the vitreous cavity was performed.3 The authors found a myopic shift in eyes that had been filled with gas compared to eyes that received no gas. In addition to a more secure position of the IOL, it may be possible to reduce this myopic shift with additional gas tamponade in the anterior chamber. HOLGER MIETZ, MD PHILIPP C. JACOBI, MD RALF KROTT, MD PETER WALTER, MD Ko¨ln, Germany
Figure 1. (Mietz) Slitlamp photograph of the eye 1 day after surgery. A large air bubble is present superiorly in the anterior chamber. The anterior chamber is deep, the pupil round, and the IOL well centered in the capsular bag. The cornea is slightly hazy because the epithelium was removed during surgery. With the help of the red fundus reflex, the margin of the air–water interface in the vitreous cavity is seen as a dark line.
References 1. Ando A, Nishimura T, Uyama M. Surgical outcome on combined procedures of lens extraction, intraocular lens implantation, and vitrectomy during removal of the epiretinal membrane. Ophthalmic Surg Lasers 1998; 29:974 –979 2. Scharwej K, Pavlovic S, Jacobi KW. Combined clear corneal phacoemulsification, vitreoretinal surgery, and intraocular lens implantation. J Cataract Refract Surg 1999; 25:693– 698 3. Suzuki Y, Sakuraba T, Mizutani H, et al. Postoperative refractive error after simultaneous vitrectomy and cataract surgery. Ophthalmic Surg Lasers 2000; 31:271–275
J CATARACT REFRACT SURG—VOL 27, JUNE 2001
803
Gas Sandwich Technique for IOL Support in Combined Cataract and Vitreoretinal Surgery
C
ombined surgical procedures involving the anterior and posterior segments of the eye are becoming more important. While vitrectomy and subsequent retinal maneuvers are often necessary to treat cases of severe retinal diseases, the population of patients requiring such interventions is growing older. In many cases, it is desirable to perform cataract surgery at the same time. The frequently used surgical armament of vitreoretinal surgeons includes tamponades of the vitreous cavity with air, longer acting gas tamponades, and silicone oil. The intraocular lens (IOL), preferably located inside the capsular bag, is an appropriate barrier for eyes filled with silicone oil. Tamponades composed of air or an expandable gas such as sulfur hexafluoride or perfluoropropane exert forces on the lens–iris diaphragm anteriorly, flattening the anterior chamber and possibly obstructing the anterior chamber angle. This may lead to anterior dislocation of the IOL and instability of the diaphragm. We operated on a 61-year-old white man with diabetes mellitus for more than 30 years who had recurrent vitreous hemorrhages in his left eye. Under general anesthesia, surgery began with phacoemulsification of the lens. The capsulorhexis was difficult because of the lack of a red fundus reflex. A foldable IOL (AcrySof威, Alcon
Pharma) with a power of 25.0 diopters was placed in the capsular bag. A standard 3-port pars plana vitrectomy was performed, which included removal of the vitreous hemorrhage and panretinal laser photocoagulation. To reduce the risk of recurrent hemorrhages in the early postoperative period, a fluid–air exchange was performed. The air pressure setting on the vitrectomy machine was 45 mm Hg. While this procedure was being done, it was noted that the anterior chamber flattened and the IOL came close to the posterior surface of the cornea. Then, air was injected into the anterior chamber to increase its volume, stabilize the lens–iris diaphragm, and keep the IOL safely positioned inside the capsular bag. In this case, gas tamponade in the posterior segment of the globe and simultaneously in the anterior chamber helped to stabilize the IOL in the early postoperative period. The danger of IOL dislocation was present in this patient because the capsulorhexis was large and not well centered. Subsequent to a poor fundus reflex, irregularities of the capsulorhexis are to be expected or may be more frequent in eyes with retinal pathology and visually disturbing cataracts. Complications reported following combined vitrectomy and phacoemulsification include fibrin reaction, posterior synechia, hyphema, and others.1,2 A recent study investigated the preoperative and postoperative refraction in combined cases in which gas tamponade of the vitreous cavity was performed.3 The authors found a myopic shift in eyes that had been filled with gas compared to eyes that received no gas. In addition to a more secure position of the IOL, it may be possible to reduce this myopic shift with additional gas tamponade in the anterior chamber. HOLGER MIETZ, MD PHILIPP C. JACOBI, MD RALF KROTT, MD PETER WALTER, MD Ko¨ln, Germany
Figure 1. (Mietz) Slitlamp photograph of the eye 1 day after surgery. A large air bubble is present superiorly in the anterior chamber. The anterior chamber is deep, the pupil round, and the IOL well centered in the capsular bag. The cornea is slightly hazy because the epithelium was removed during surgery. With the help of the red fundus reflex, the margin of the air–water interface in the vitreous cavity is seen as a dark line.
References 1. Ando A, Nishimura T, Uyama M. Surgical outcome on combined procedures of lens extraction, intraocular lens implantation, and vitrectomy during removal of the epiretinal membrane. Ophthalmic Surg Lasers 1998; 29:974 –979 2. Scharwej K, Pavlovic S, Jacobi KW. Combined clear corneal phacoemulsification, vitreoretinal surgery, and intraocular lens implantation. J Cataract Refract Surg 1999; 25:693– 698 3. Suzuki Y, Sakuraba T, Mizutani H, et al. Postoperative refractive error after simultaneous vitrectomy and cataract surgery. Ophthalmic Surg Lasers 2000; 31:271–275
J CATARACT REFRACT SURG—VOL 27, JUNE 2001
803