Combining phacoemulsification with vitrectomy for treatment of macular holes

AIM: To describe the results of combined phacoemulsification, insertion of posterior chamber intraocular lens (PCIOL), and pars plana vitrectomy for patients with macular hole. METHODS: A case series of 89 consecutive patients with macular hole who underwent combined phacoemulsification, insertion of PCIOL, posterior capsulectomy, and pars plana vitrectomy. RESULTS: 80 of 89 patients (89%) had their holes closed with the combined surgery. Four of the nine patients who failed had their holes closed with one further procedure. Of the 89 patients operated on, 61 (65%) had vision of 20/40 or better. Three patients (3%) had Snellen acuity of less than 20/400 postoperatively. Three patients (3%) developed retinal detachments, one with proliferative vitreoretinopathy (PVR). Eight patients (9%) developed CMO. Three patients developed late reopening of their macular holes after remaining closed for 9 months or more. CONCLUSION: Combined phacoemulsification, insertion of PCIOL, and pars plana vitrectomy surgery can be used to treat macular holes. Combining cataract surgery with vitrectomy surgery may prevent a later second operation for post-vitrectomy cataract formation.     

超声乳化人工晶状体植人联合玻璃体切除术治疗增生型糖尿病视网膜病变

目的评价晶状体超声乳化、囊袋内人工晶状体植入联合玻璃体切除术治疗增生型糖尿病视网膜病变（PDR）的临床效果。方法回顾性分析合并不同程度白内障的增生型糖尿病视网膜病变6l例（66眼）。其中PDRlV期20眼,V期33眼,Ⅵ期13眼。实施晶状体超声乳化、囊袋内人工晶状体植人联合玻璃体切除术。观察术后视力改善程度和术中术后并发症。结果术后视力改善：PDR1V期19眼（95．0％）,V期28眼（84．8％）,Ⅵ期13眼（38．5％）。术后视力低下者多伴有明显的糖尿病黄斑病变。术中术后主要并发症包括：医源性裂孔7眼（10．6％）;玻璃体积血,术中17眼（25．8％）,术后7眼（10．6％）;角膜上皮延期愈合9眼（13．6％）;角膜水肿8眼（12．1％）。结论超声乳化、人工品状体植入联合玻璃体切除术治疗合并不同程度白内障的增生型糖尿病视网膜病变是安全有效的,可使大多数患者视力改善,避免玻切术后并发白内障再次手术。糖尿病黄斑病变是影响术后视力提高的主要原因。     

Combined surgery, phacoemulsification, implantation of intraocular lens and pars plana vitrectomy

PURPOSE: To evaluate the effectiveness, technical feasibility and incidence of complications after combining pars plana vitrectomy, phacoemulsification and intraocular lens implantation. MATERIAL AND METHODS: The results of combined vitreoretinal and cataract surgery in 100 eyes of 96 patients were retrospectively and prospectively analyzed. The mean follow-up period was 8.4 months. All patients had clinically significant lens opacities and vitreoretinal pathology requiring pars plana vitrectomy. Indications for vitreoretinal surgery included: persistent vitreous haemorrhage (28 eyes), vitreous hemorrhage combined with tractional retinal detachment (50 eyes), tractional retinal detachment without vitreous haemorrhage caused by proliferative diabetic retinopathy (7 eyes), rheumatogenous retinal detachment with proliferative vitreoretinopathy (10 eyes) and dislocated crystalline lens in the vitreous (5 eyes). RESULTS: Postoperatively, best corrected visual acuity improved in 81 eyes (81%)- by two lines or more in 31 eyes (31%) - by less than two lines in 50 eyes (50%). In 14 eyes (14%) visual acuity was unchanged and was worse in 5 cases (5%). Postoperative complications included fibrin reaction, posterior synechias of the iris, vitreous hemorrhage, neovascular glaucoma, posterior capsule opacification, redetachment of retina. CONCLUSIONS: Our cases confirm previous study, that performing phacoemulsification, IOL implantation and vitrectomy in one operation is safe and allows visual recovery with good technical results.     

晶状体超声乳化联合玻璃体手术治疗合并白内障的增生性糖尿病视网膜病变

目的分析晶状体超声乳化联合玻璃体手术治疗合并白内障的增生性糖尿病视网膜病变(PDR)的疗效。设计回顾性临床病例系列。研究对象123只合并不同程度白内障的PDR患眼。方法对123只合并不同程度白内障的PDR患眼实施晶状体超声乳化联合玻璃体手术治疗,同时I期植入人工晶状体(IOL),观察术后视力改善程度及术中术后并发症。主要指标术后视力改善程度、术后并发症发生率。结果123眼均实施晶状体超声乳化联合玻璃体手术,并同时一期植入IOL于囊袋内。随访时间3￣21月(平均10个月)。99眼(81%)术后均有不同程度的视力改善。其中93眼(76%)术后视力提高2行或以上。术后无明显角膜水肿和角膜内皮失代偿发生。1例I型糖尿病患者术后6个月发生新生血管性青光眼;1眼术后发生视网膜脱离,再次手术后复位;4眼因玻璃体腔出血再次手术。术后视力无明显改善或视力提高不足2行的病例均合并不同程度的糖尿病黄斑病变。结论晶状体超声乳化联合玻璃体手术是提高合并白内障的PDR患者视力的有效手段。糖尿病黄斑病变是影响术后视力提高的主要因素。(眼科,2006,15:198-201)     

Pars plana vitrectomy in proliferative diabetic retinopathy

In this contribution the authors present the results of treatment by pars plana vitrectomy in a consecutive series of 200 patients with proliferative retinopathy. Anatomical success was achieved in 82% of the cases of simple vitreous hemorrhages, in 63% and 67% respectively of the cases of traction detachment with or without vitreous hemorrhage, and in 55% of the cases of combined rhegmatogenous and traction detachment. Postoperative visual success was generally dependent on preoperative macular findings. Visual success was achieved in 71% of cases where the macula was attached preoperatively, as opposed to only 38% of the patients in whom it was preoperatively detached. Intraoperative retinal complications were less than 1% in cases of simple vitreous hemorrhage, rose to 13%-15% in cases of traction detachment and were quite common (32%) in cases of combined rhegmatogenous and traction detachment. A major goal of this paper was to show that anatomical and visual success as well as intraoperative complications were highly dependent on the degree of surgical difficulty and the stage of the disease. The results support the concept that vitreous surgery should be considered early in the late stages of proliferative diabetic retinopathy.     

Incidence of rhegmatogenous retinal detachment after vitrectomy in eyes of diabetic patients

PURPOSE: To assess the incidence of rhegmatogenous retinal detachment (RRD) after pars plana vitrectomy (PPV) among diabetic patients with complications of proliferative diabetic retinopathy. METHODS: Ninety-three eyes of diabetic patients-who underwent PPV with or without intraocular gas tamponade for complications of proliferative diabetic retinopathy-were reviewed retrospectively. Indication for vitrectomy was vitreous hemorrhage in 80 patients (86.1%), tractional retinal detachment in 3 (3.2%), and vitreous hemorrhage associated with tractional retinal detachment in 10 (10.7%). RESULTS: Four (4.3%) of 93 eyes developed an RRD after vitrectomy. The primary reason for vitrectomy was recurrent or nonresolving vitreous hemorrhage. The retina was attached with one additional surgical procedure in two of these eyes; the other two had to undergo a third operation before attachment was achieved. CONCLUSION: RRD occurs in a small percentage of patients after PPV with or without gas tamponade for vitreous hemorrhage or tractional retinal detachment caused by proliferative diabetic retinopathy. Thorough postoperative follow-up is important to make early diagnosis and intervention possible.     

增生性糖尿病视网膜病变合并白内障的联合手术治疗

目的探讨玻璃体手术联合晶状体超声乳化治疗增生性糖尿病性视网膜病变（PDR）合并白内障的临床疗效。方法分析19例（20只限）增生性糖尿病性视网膜病变合并不同程度白内障患者行白内障超声乳化联合玻璃体手术同时进行人工晶状体囊袋内植入的临床资料，观察术后视力改善程度及术中术后并发症。结果随访2—16个月，所有术眼人工晶状体位置良好，手术后20只限中有16只限（80％）视力有不同程度的提高，其中视力提高二行以上13只限（65％）；视力较术前无改善4只限（20％）。术后视力恢复不佳的原因主要与不同程度的糖尿病黄斑病变、视网膜广泛缺血有关。术后并发症包括高眼压、虹膜后粘连、玻璃体腔再出血、视网膜再脱离、晶状体后囊混浊及新生血管性青光眼等。结论玻璃体手术联合白内障超声乳化人工晶状体植入术治疗增生性糖尿病性视网膜病变合并白内障是安全和有效的，可使大多数患者视力改善，且无明显并发症。     

Combined phacoemulsification,intraocular lens implantation,and vitrectomy for eyes with coexisting cataract and vitreoretinal pathology

PURPOSE: To report the preoperative, intraoperative, and postoperative outcomes of combining phacoemulsification and posterior chamber intraocular lens (IOL) implantation with pars plana vitrectomy in eyes with significant cataract and coexisting vitreoretinal pathology. DESIGN: Retrospective, consecutive, interventional case series. METHODS: Charts of patients undergoing combined procedures at the Wilmer Ophthalmologic Institute between March 1995 and May 2000 were reviewed. RESULTS: In all, 122 eyes of 111 patients were identified. Patient ages ranged from 27 to 89 years (mean 65). Forty-three eyes had diabetic retinopathy; 11 had undergone vitrectomy previously. Macular pathology (hole, membrane, choridal neovascularization) was present in 69 eyes. The most common indications for surgery were diabetic vitreous hemorrhage, macular hole, epiretinal membrane, and retinal detachment. In all cases, phacoemulsification and IOL implantation were performed before vitreoretinal surgery. Preoperative vision ranged from 20/30 to light perception and postoperative vision ranged from 20/20 to no light perception. In 105 patients vision improved, in 7 there was no change, and in 10 vision decreased. Postoperative complications included opacification of the posterior capsule, increased intraocular pressure, corneal epithelial defects, vitreous hemorrhage, retinal detachment and iris capture by the IOL. CONCLUSIONS: Combined surgery is a reasonable alternative in selected patients. Techniques that may simplify surgery and reduce complications include: careful, limited, curvilinear capsulorhexis; in-the-bag placement of IOLs; use of IOLs with larger optics; suturing of cataract wounds before vitrectomy; use of miotics and avoidance of long-acting dilating drops in patients with intravitreal gas; and use of wide-field viewing systems.     

Vitreoretinal surgery for complications of branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) is second only to diabetic retinopathy as a cause of retinal vascular disease. Vision loss from BRVO may be associated with multiple causes, including macular edema, macular ischemia, foveal hemorrhage, vitreous hemorrhage, epiretinal membrane, and retinal detachment. The few published studies that report outcomes of pars plana vitrectomy for complications of BRVO consist only of case reports and small case series, limitations of which include small sample sizes and lack of comparison groups. Given the variable outcomes among patients with untreated BRVO, comparison groups are necessary for accurate evaluation of the efficacy of pars plana vitrectomy for BRVO.     

严重PDR玻璃体切割术后雷珠单抗注射的效果观察

目的：对严重增殖性糖尿病视网膜病变的患者行玻璃体切割术后行雷珠单抗注射的效果观察。方法：回归性分析。12例严重增殖性糖尿病视网膜病变患者(12眼)接受睫状体平坦部玻璃体切割术,同时给予硅油、惰性气体或者平衡液的玻璃体腔填充。在手术结束的同时给予雷珠单抗的玻璃体腔注射。结果：随访时间平均为2.75 mo。这12眼中分别包括玻璃体积血(1眼);玻璃体积血伴纤维血管化增生(1眼);玻璃体积血伴牵拉性视网膜脱离(3眼);纤维血管化增生伴牵拉性视网膜脱离(2眼);玻璃体积血伴新生血管性青光眼伴牵拉性视网膜脱离(1眼);玻璃体积血伴纤维血管化增生伴牵拉性视网膜脱离(2眼);玻璃体积血伴纤维血管化增生伴新生血管性青光眼伴牵拉性视网膜脱离(1眼);玻璃体积血伴牵拉性孔源性视网膜脱离(1眼)。12眼中,8眼行玻璃体腔硅油填充,2眼行惰性气体填充,2眼行平衡液填充。所有的患者之前均未接受任何治疗。视网膜脱离复位率为10/10(100%)。1眼术后出现前房积血。9眼术后最佳矫正视力较术前提高,2眼无明显变化,1眼较术前下降。 OCT检查显示8眼术后未见黄斑水肿。结论：玻璃体切割术后雷珠单抗注射对严重增殖性糖尿病视网膜病变患者有明显的治疗效果：手术成功率明显提高;患者视力显著提高;糖尿病黄斑水肿的发生概率减少;术中及术后并发症的发生率降低。     

Combined pars plana vitrectomy and phacoemulsification with intraocular lens implantation in severe proliferative diabetic retinopathy.

BACKGROUND AND OBJECTIVE: To evaluate the results of combined vitrectomies and intraocular lens implantations in cases of proliferative diabetic retinopathy. PATIENTS AND METHODS: Data from procedures on 117 eyes (91 patients) undergoing combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation for the complications of proliferative diabetic retinopathy were analyzed retrospectively. Follow-up ranged from 8 to 64 months (median = 25 months). RESULTS: Retinal tears were the most frequent intraoperative problems (19%). Limited postoperative fibrin formation occurred in 22% of eyes. Within 6 months, 7% developed glaucoma and 2% showed new anterior segment rubeosis. Overall, 10% underwent secondary surgical procedures as follows: lavage for hemorrhage (n = 3), silicone oil exchange after 7 days for focal rebleeding (n = 1), silicone oil surgery for retinal detachment after gas resorption (n = 1), and lavage for late vitreous hemorrhage (7 to 13 months) (n = 4). Half of the secondary procedures were necessitated within 3 months of the original surgery. CONCLUSIONS: Combined surgery in proliferative diabetic retinopathy is safe and effective. It should be considered when lens opacities are either present or likely to develop soon.     

Macular hole formation in diabetic retinopathy: the role of coexisting macular edema

The aim of this study was to characterise different etiologies for the development of macular holes in diabetic retinopathy. We examined 8 eyes of 8 patients with known diabetic retinopathy who had developed a macular hole. These were classified as follows: related to macular edema (4 eyes), non-related to macular edema (2 eyes), intraoperative (1 eye) or postoperative (1 eye) after pars plana vitrectomy for proliferative diabetic retinopathy. In three patients the macular holes were treated with pars plana vitrectomy and fluid air exchange. In diabetic eyes with macular edema, macular holes may develop because of intraretinal exudation combined with increased vitreomacular attachments and tractions. The mechanism of macular hole formation in diabetic eyes without macular edema probably results from the same increased tangential vitreous traction which is seen in idiopathic age-related macular holes. Iatrogenically induced macular holes during pars plana vitrectomy for proliferative diabetic retinopathy may be also due to intraoperative vitreoretinal tugging. Finally, macular holes developing after vitrectomy may have an etiology not related to vitreous tractions or attachments. This revised version was published online in July 2006 with corrections to the Cover Date.     

The Clinical Features of Macular Pucker Formation after Pars Plana Vitrectomy for Primary Rhegmatogenous Retinal Detachment Repair

Purpose

To investigate the incidence and predisposing factors of macular pucker formation after pars plana vitrectomy in patients who developed primary rhegmatogenous retinal detachment.

Methods

We retrospectively reviewed a consecutive series of 284 eyes in 284 patients who underwent primary retinal detachment repair by pars plana vitrectomy alone between January 1, 2009 and December 31, 2010. Patients with a history of retinal surgery or another visually significant ocular problem were excluded.

Results

Postoperatively, of the 264 eyes that completed at least six months of follow-up, 16 (6.1%) eyes developed obvious macular pucker at clinical examination. Of these 16 eyes, ten (70.0%) underwent repeat vitrectomy with membrane peeling for macular pucker removal during the follow-up period. The mean time from primary vitrectomy for the retinal reattachment to the secondary vitrectomy with membrane peeling for macular pucker was 7.9 months. The mean improvement in vision after membrane peeling surgery was 0.37 (logarithm of the minimum angle of resolution). Using an independent t-test, chi-square test, and Mann-Whitney U-test, we found that the number or size of retinal break and vitreous hemorrhage could be significant risk factors of macular pucker.

Conclusions

In our study, 6.1% of eyes which underwent pars plana vitrectomy alone for primary retinal detachment developed a postoperative macular epiretinal membrane. Multiple or large retinal breaks and postoperative vitreous hemorrhage were related to macular pucker formation. Overall, the 70.0% of eyes which underwent secondary vitrectomy with membrane peeling for removal of macular pucker showed a favorable visual outcome.     

Efficacy of intravitreal triamcinolone acetonide in the visualization of the vitreous during pars plana vitrectomy

PURPOSE: To retrospectively evaluate the efficacy of triamcinolone acetonide (TA) injection during pars plana vitrectomy, to facilitate the visualization of the internal limiting membrane (ILM), residual vitreous cortex (RVC) and preretinal membranes. MATERIAL AND METHODS: Pars plana vitrectomy was performed in 164 patients due to rhematogenous retinal detachment, vitreous hemorrhage, macular hole, lens luxation, endophthalmitis, intraocular foreign body, malignant glaucoma, preretinal membrane and proliferative diabetic retinopathy. After surgical separation of the posterior vitreous and removal of any visible epiretinal membrane, TA suspension was injected over the posterior pole into the vitreous cavity. Then, visualized RVC was removed and ILM peeling was performed. RESULTS: Upon intravitreal injection of TA, vitreous and ILM could be visualized by numerous particles of TA dispersed as white specks. RVC and ILM were completely removed in all patients. No complications related to the use of TA were encountered, even after complex procedures such as, vitrectomy combined with scleral buckling or phakoemulsification surgery in a long term follow up. CONCLUSIONS: Intraoperative visualization of RVC and ILM with intravitreal TA was found to be a useful adjunct to pars plana vitrectomy. This technique may facilitate both removal of epiretinal membrane and separation of vitreous, especially in patients with undetached vitreous.     

A phacovitrectomy with a clear corneal incision for a full-thickness macular hole

PURPOSE: To describe the results of a pars plana vitrectomy, combined with phacoemulsification, using a sutureless, superotemporal, clear corneal incision for patients with a macular hole. METHODS: This study reviewed the records of 22 patients (22 eyes) who underwent a phacoemulsification with the insertion of an acrylic intraocular lens, using a 3.2 mm superotemporal clear corneal incision and a pars plana vitrectomy with an internal limiting membrane peeling in one session, for the treatment of a macular hole. RESULTS: All 22 patients had their macular holes closed using the combined surgical procedures. The mean preoperative visual acuity was 0.086, and the mean postoperative visual acuity was 0.173. This improvement was statistically significant (paired Student's t-test, p < 0.05). No patients developed posterior capsular opacity, retinal detachment, or a cystoid macular edema. The surgically induced astigmatism (SIA) was 0.808 diopters (0.808 +/- 0.761) two months after surgery. CONCLUSIONS: Combining cataract surgery with vitrectomy can achieve visual rehabilitation in the early postoperative period without requiring post-vitrectomy cataract surgery. A sutureless clear corneal incision, used in this procedure, can minimize the SIA and promote postoperative wound healing. If sutureless, transconjunctival, pars plana vitrectomy can be used more widely in the future, then the simplified, combined cataract surgery using a small clear corneal incision will also become more common, hence decreasing operation time, and hastening postoperative recovery.     

高度近视黄斑孔性视网膜脱离手术探讨

目的 评价黄斑加固联合内界膜剥离、注气治疗早期高度近视黄斑孔性视网膜脱离的效果.方法 10例10只眼早期高度近视黄斑孔性视网膜脱离进行了黄斑加固、玻璃体切除、内界膜剥离、玻璃体腔注气治疗.均有黄斑部视网膜脱离,眼轴长度均超过27.0 mm,均有黄斑全层破孔.视网膜已僵硬者排除在外.术后随访6～18个月.结果 10只眼初次手术后,视网膜全部复位.但1只眼1月后视网膜再次脱离,再次行玻璃体腔注气术后视网膜复位,黄斑孔未闭合.10只眼中有5只眼黄斑孔闭合;5只眼黄斑孔部分区域闭合,部分组织缺损（1个月后黄斑孔周围行激光封闭）.术中未见医源性裂孔形成,术后1只眼玻璃体积血,2周后自行吸收.余术后无眼内出血或眼内炎等严重并发症发生.结论 黄斑加固联合内界膜剥离注气术是治疗早期高度近视黄斑孔性视网膜脱离安全有效的手术方法.能提高视网膜解剖复位率、黄斑孔闭合率.     

Clinical results in vitrectomy for diabetic traction retinal detachment.

A series of 75 eyes underwent pars plana vitrectomy for progressive diabetic traction retinal detachment of the macula. In all cases, the media was sufficiently clear to allow preoperative macular examination. The overall visual improvement was higher in phakic eyes (80%) than aphakic eyes (72%) and the rate of neovascular glaucoma was less in phakic eyes. The difference was not statistically significant, however. The final visual acuity corresponded to the degree of preoperative visual deterioration. Thus, surgery during the rapidly evolving proliferative and retracting process did not adversely affect the visual success rate when compared to previous reports on longstanding vitreous hemorrhage.     

Vitrectomy in the management of diabetic eye disease.

Vitrectomy techniques including endolaser photocoagulation allow visual rehabilitation in many eyes that are otherwise untreatable. Discerning the indications and timing for diabetic vitrectomy is increasingly important as the treatment of complications of diabetic retinopathy continues to undergo modification and redefinition. The most common indications for diabetic vitrectomy include: 1) severe nonclearing vitreous hemorrhage; 2) traction retinal detachment recently involving the macula; 3) combined traction and rhegmatogenous detachment; 4) progressive fibrovascular proliferation; and 5) rubeosis iridis and vitreous hemorrhage for eyes in which the media opacity has prevented adequate laser photocoagulation. Other less common indications in selected cases include dense premacular hemorrhage, ghost cell glaucoma, macular edema with premacular traction, cataract preventing treatment of severe, proliferative diabetic retinopathy, anterior hyaloidal fibrovascular proliferation, and fibrinoid syndrome with retinal detachment. The rationale and surgical objectives are discussed and results are summarized.     

Combined phacoemulsification, vitrectomy, foreign-body extraction, and intraocular lens implantation

PURPOSE: To assess the outcome of simultaneous phacoemulsification, pars plana vitrectomy, intraocular foreign-body extraction, and intraocular lens (IOL) implantation. SETTING: SSK Ankara Eye Hospital, Department of Vitreoretinal Surgery, Ankara, Turkey. METHODS: Seventeen patients with corneal perforation, intraocular foreign body, vitreous hemorrhage, and lens opacity had simultaneous clear corneal phacoemulsification, pars plana vitrectomy, intraocular foreign-body extraction, and IOL implantation. RESULTS: Postoperative complications included massive retinal fibrosis in 2 patients, retinal detachment in 1, and cilioretinal artery occlusion in 1. At a mean follow-up of 15.2 months, best corrected visual acuity improved in the remaining 13 eyes (76%). The IOL was stable in all cases. CONCLUSION: Combined phacoemulsification with IOL implantation and vitreoretinal surgery was safe in selected cases of penetrating ocular trauma resulting from an intraocular foreign body.     

Entry-site-related retinal detachment after pars plana vitrectomy

PURPOSE: Today, pars plana vitrectomy represents a standard surgical procedure for a number of retinal diseases that were previously considered inoperable. The aim of the present study is to investigate the entry site of pars plana vitrectomy as a possible source of retinal detachment. METHODS: We reviewed retrospectively all cases of uncomplicated pars plana vitectomies because of macular hole, macular pucker and diabetic macular oedema performed in our department between 1 January 2001 and 7 July 2004. RESULTS: Over 3.5 years, 244 pars plana vitrectomies because of macular disease were performed. Sclerotomy-related retinal detachment was observed in 11 (4.5%) cases. These retinal detachments occurred at a mean of 37 (2-100) days after surgery. They appeared within the first 4 weeks in 55% of the cases. CONCLUSION: Iatrogenic retinal breaks and detachment continue to be a severe complication of pars plana vitrectomy, despite improvements in instrumentation and surgical techniques. A 4.5% incidence of sclerotomy-related retinal detachment after simple vitrectomy calls for action. Current approaches to reduce this complication - such as circular peripheral cryoretinopexy, scleral buckling or 360 degrees laser treatment - are invasive. We recommend extended vitreous base cleaning with scleral indentation and examination of the entry sites, performed with a three-mirror lens or via careful indirect ophthalmoscopy into the periphery, 4 weeks after surgery.