ADVANCEMENTS IN SURGICAL TECHNOLOGY AND EFFICIENCY
Combining Sutureless 23-Gauge Vitrectomy and Phacoemulsification
BY TIMOTHY G. MURRAY, MD, MBA, FACS
As vitreoretinal surgeons, we know cataract is the most common comorbidity in patients with vitreoretinal disease, and it can have a major impact on our patients' final visual acuity after primary vitreoretinal surgery. In addition, cataract surgery after vitreoretinal surgical repair may lead to recurrence of vitreoretinal pathology.
In the United States, the most common approach to these cases is to address the cataract first in a separate anterior segment procedure and then perform pars plana vitrectomy at a later time, or vice versa. Outside the United States, vitreoretinal surgeons frequently address these pathologies in a single combined procedure to maximize the patient's recovery and enhance early visual rehabilitation.
To explore the utility of this combined surgery approach, my colleagues and I did a retrospective review of cases managed at Bascom Palmer Eye Institute in Miami.
We looked at cases involving 114 eyes of 111 patients who had significant vitreoretinal pathology and concomitant anterior segment lenticular changes. Surgeons performed combination sutureless 23-gauge vitrectomy and phacoemulsification.
In this series, evaluated by Robert Sisk, MD, the mean age was 76 years, and we had a fairly equal distribution of men and women. My practice is predominantly ocular oncology, so about 42% of these patients had an intraocular malignancy at the time of the combined surgery. Another 26% had epiretinal membrane and vitreomacular traction alterations, and approximately 23% presented with diabetic tractional complications.
Follow-up averaged 8 months, with a range of 3 months to 2 years. Initially, we used the ACCURUS® platform; later, we transitioned to the integrated CONSTELLATION® Vision System. Currently, all combined cases are managed exclusively with the CONSTELLATION® Vision System.
Among the new features of the CONSTELLATION® Vision System, the probe technology is a significant advancement, allowing us to manage a variety of pathologies with appropriate wound construction. In combined anterior/posterior surgery, trocar placement is particularly important to obtain access to the anterior segment (Figure 1). After I address the anterior segment pathology, I move to the posterior segment.
Figure 1. Trocar placement is particularly important in combined anterior/posterior surgery.
When operating in the posterior segment alone, I often can operate through a small pupil with wide field imaging. The CONSTELLATION® System is excellent for those cases. In cases where I want to combine anterior and posterior segment surgery, however, I often use iris hooks. In these cases, excellent visualization of the anterior segment enhances the surgical safety margin for the procedure.
OUTCOMES AND POST-OP COMPLICATIONS
One of the issues with micro-incision vitrectomy surgery has been the potential for postoperative complications, specifically hypotony, choroidal detachment or endophthalmitis.1-3 We felt this surgical series would be an excellent opportunity for us to evaluate these potential complications, because these eyes were at greatest risk for complications. We specifically chose not to suture the sclerotomy sites in these cases.
Posterior chamber IOLs were placed in all eyes without difficulty, and we had no intraoperative complications. Postoperatively, the corneas were clear, with minimal stromal alterations. We had no cases of endophthalmitis. We had capsular tears in about 13% of cases, and in this series of 400 sclerotomies, utilizing a 23-gauge system, we had postoperative hypotony in 4 cases. Visual acuity improved significantly, with 76% of patients having a 2-line or greater improvement. In summary, the CONSTELLATION® Vision System enhanced the combined application of posterior vitrectomy and anterior phacoemulsification.
In my experience, the fluidic stability of the 23-gauge CONSTELLATION® Vision System facilitates anterior/posterior segment surgery, allowing us to safely address comorbidity and concomitant cataracts with the potential to enhance rapid visual rehabilitation for our patients. Thanks to this technology platform, I believe we will see more surgeons combine procedures for anterior and posterior segment pathology.
1. Acar N, Kapran Z, Unver YB, Altan T, Ozdogan S. Early postoperative hypotony after 25-gauge sutureless vitrectomy with straight incisions. Retina. 2008;28:545-552.
2. Kunimoto DY, Kaiser RS, Wills Eye Retina Service. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy. Ophthalmology. 2007;114:2133-2137.
3. Scott IU, Flynn HW Jr, Dev S, et al. Endophthalmitis after 25-gauge and 20-gauge pars plana vitrectomy: incidence and outcomes. Retina. 2008;28:138-142.
Timothy G. Murray, MD, MBA, FACS, practices at Bascom Palmer Eye Institute, University of Miami Miller School of Medicine. Dr. Murray is a consultant for Alcon Laboratories, Inc.