Phacoemulsification and vitrectomy combo shows no added benefit in improving RD surgical outcome
Pars plana vitrectomy (PPV) is currently the most common surgical technique used for the repair of rhegmatogenous retinal detachment (RRD), particularly in older and pseudophakic patients. Recently, the combination of phacoemulsification and intraocular lens (IOL) implantation with vitrectomy, also known as phacovitrectomy, has been growing in popularity in patients with significant cataract and coexisting vitreoretinal pathologies. This combined procedure has advantageous for both patients with RRD and surgeons; it avoids the need for later potentially difficult cataract surgery, decreases the risks and costs associated with a second surgery, and provides easy access to peripheral retina during surgery without fear of lenticular touch.
There are concerns that phacovitrectomy would be more challenging for a retina surgeon who is inexperienced in cataract surgery because of prolonged surgical time or more complications during the cataract surgery (e.g., corneal opacity, pupil constriction, and posterior capsular rupture), which made subsequent vitrectomy more difficult. Kim et al carried out a study aimed to compare the efficacy and safety of phacovitrectomy versus lens sparing vitrectomy for uncomplicated RRD treatment depending on the surgeon's surgical experience.
Authors retrospectively reviewed the medical records of 193 patients with primary rhegmatogenous retinal detachment who underwent either lens-sparing vitrectomy (n = 111) or phacovitrectomy (n = 82). Patients were operated by two experienced surgeons or eight vitreoretinal fellows and had a minimum follow-up of 6 months. Anatomical success rate, postoperative complications, and functional outcomes were compared.
Primary success was defined as retinal reattachment after a single procedure, and primary failure was considered as retinal re-detachment during the follow-up of at least 6 months. Final anatomical success occurred when the retina was found attached at the final follow-up visit. The operating time was recorded by operating room staff. Operating time was defined as the time at which surgery completed minus the time when surgery started.
- A total of 193 phakic eyes of 193 RRD patients (mean age, 54.3 ± 11.8 years; female, 45.1%) receiving either lens-sparing vitrectomy or phacovitrectomy were included
- Primary anatomical success rate was 92.8% (103/111) for lens-sparing vitrectomy and 91.5% (75/82) for phacovitrectomy (P = 0.733).
- The fellows had lower success rate after phacovitrectomy compared with the experts, but not statistically significant (85% [34/40] vs. 97.6% [41/42], P = 0.054).
- During phacovitrectomy, one zonulysis case in the experts group and four posterior capsular rupture cases in the fellows group were noted.
- Cystoid macular edema was found only after phacovitrectomy (12.2% [10/82]), and epiretinal membrane occurred more after phacovitrectomy than after lens-sparing vitrectomy (28% [23/82] vs. 8.1% [9/111], P < 0.001).
- There was no difference in the occurrence of cystoid macular edema and epiretinal membrane after phacovitrectomy between two surgeon groups (P = 0.514, 0.701, respectively).
- In this study, the primary anatomical success rate of lens-sparing vitrectomy and phacovitrectomy for phakic RRD was more than 90%, and there was no significant difference between the two procedures. In the fellow surgeon group, however, the success rate of phacovitrectomy was 85%, which was 12.6% lower than that by the experienced surgeon group, although it was not statistically significant (P = 0.054).
The authors attributed the high success rate to good visibility and safe shaving of the vitreous base during surgery in the nonphakic eyes. However, it is uncertain whether this benefit could also be applicable to the phacovitrectomy procedure performed by beginners, because the additional procedure (i.e., accompanying cataract surgery) could prolong the time of surgery and make subsequent vitrectomy more difficult because of pupil constriction or corneal edema. It greatly matters if the operator is not familiar with cataract surgery.
In the fellow surgeon group, however, the success rate was relatively lower with phacovitrectomy, suggesting that there was a negative repercussion from the accompanying cataract surgery. A retina surgeon who is inexperienced in phacoemulsification tends to induce more complications related to cataract surgery, in which case subsequent vitrectomy may become more complicated.
In this study, only one case (1.6%) in the experienced surgeon group and two cases (3.8%) in the fellow surgeon group underwent phacovitrectomy because of lenticular touch during vitrectomy. "Lens touch" is a common complication of lens-sparing vitrectomy, but not a frequent complication in this study.
Cataract formation and progression have been regarded as an inevitable complication after vitrectomy or gas tamponade. Thus, cataract development after vitrectomy has been considered as one of the major reasons for favoring phacovitrectomy. In this study, 56.8% of overall patients undergoing lens-sparing vitrectomy underwent subsequent cataract surgery during the follow-up period.
Taken together, despite cataract progression and formation after vitreoretinal procedures, the rate of cataract extraction after vitreoretinal surgery was not particularly high, which means that a considerable portion of patients did not require subsequent cataract surgery. Study also showed phacovitrectomy induced more myopic shift than subsequent cataract surgery.
Taken together, the decision to perform phacovitrectomy because of ensuing cataract problem is the lack of concrete evidence. Especially if the operator is inexperienced in cataract surgery, it is better to focus on the primary retinal pathology through vitrectomy first and later refer to an anterior segment surgeon or be supervised by senior surgeons for subsequent cataract surgery.
"In summary, because the experienced retinal surgeon who is familiar with cataract surgery showed high success rate of RRD vitrectomy regardless of whether the cataract surgery was combined or not, the surgical procedure could be selected based on the surgeon's preference or the patient's need. In contrast, surgeon in training should be careful when interpreting previous reports that phacovitrectomy is advantageous, because accompanying cataract surgery could be an extra burden to them and consequently may affect the surgical outcome of vitrectomy for primary RRD."
Source: Kim et al; Retina, The Journal Of Retinal And Vitreous Diseases 41:1597–1604, 2021