Small incision phacoemulsification and microincision cataract surgery (MICS) involving sub-2 mm clear corneal incisions are safe and effective standard surgical procedures [
The aim of this present interventional case series study was to retrospectively investigate and review surgical indications, intraoperative and postoperative complications, and visual acuity outcomes in eyes undergoing combined coaxial 2.2 mm small incision cataract surgery with intraocular lens (IOL) implantation and hybrid 25-27-gauge MIVS for the treatment of vitreoretinal disease and concurrent age-related cataract.
The authors report a single-center, retrospective, consecutive surgical case series that underwent small incision cataract surgery with IOL implantation combined with transconjunctival sutureless hybrid 25-27-gauge vitrectomy. All medical records and surgical charts of 102 patients (116 eyes) who underwent combined small-gauge phacovitrectomy surgery performed at Helios Klinikum Pforzheim, Pforzheim, Germany, between January and December 2014 were reviewed. Cases operated using 23-gauge vitrectomy or microincision coaxial phacoemulsification, where postoperative follow-up was less than 2 months, were excluded. Overall, 55 patients (55 eyes) were identified who had undergone coaxial small incision cataract surgery and IOL implantation combined with hybrid 25-27-gauge MIVS, who were all included in this study.
All patients in this series had preoperative lens opacification, which was graded mild or moderate in 36 of 55 eyes (65.5%). Demographic data and preoperative patient characteristics are presented in Table
Demographic data and preoperative clinical features.
Variable | Data |
---|---|
Number of patients (eyes) | 55 (55) |
Gender (male : female) | 23 : 32 |
Age (mean ± SD) | 70.0 ± 10.33 years |
Laterality (OD : OS) | 26 : 29 |
Preoperative logMAR BCVA (mean ± SD) | 0.52 ± 0.6 |
SD, standard deviation; OD, right eye; OS, left eye; logMAR, logarithm
of the minimum angle of resolution; BCVA, best-corrected visual acuity.
Vitreoretinal indication and cataract grade.
Variable | Patients, |
---|---|
Diagnosis | |
Rhegmatogenous retinal detachment | 2 (3.6) |
Epiretinal membrane | 26 (47.3) |
Macular hole stage 4 | 11 (20) |
Vitreous hemorrhage | 3 (5.5) |
Vitreomacular traction | 6 (10.9) |
Proliferative diabetic retinopathy | 5 (9.1) |
Subretinal hemorrhage | 2 (3.6) |
Cataract grade | |
Mild nuclear sclerosis ± cortical spoking | 22 (40) |
Moderate | 14 (25.5) |
Dense brunescent | 12 (21.9) |
Dense posterior subcapsular | 3 (5.5) |
Degree and type of cataract not recorded | 4 (7.3) |
Combined phacovitrectomy procedures were carried out in single-session operations performed by the same surgeon, Fabian Höhn. Surgeries were completed throughout using a single phacovitrectomy console and the EVA ophthalmic surgical system (DORC International, Zuidland, Netherlands), together with a 25-gauge two-dimensional cutting (TDC) vitrectomy probe. The EVA surgical system is designed for use in anterior and posterior segment procedures that require infusion, vitreous cutting, aspiration, illumination, irrigation, lens emulsification and fragmentation, cautery, and diathermy as well as photocoagulation.
Preoperative data collected included patient demographics, visual acuity, intraocular pressure (IOP) measured in millimeters of mercury (mmHg) by Goldmann applanation tonometry, and diagnostic indication for combined phacovitrectomy surgery. Intraoperative data collected included suture placement if required, corneal incision and sclerotomy wound stability, and other complications observed during surgery. Postoperative visual acuity, IOP, degree of ocular inflammation, and IOL-related complications were analyzed.
Following consultation and informed consent, patients underwent combined phacovitrectomy surgery under general anesthesia. Coaxial small incision cataract surgery was performed through a 2.2 mm corneal incision. A 27-gauge valved trocar (DORC) was preplaced in the inferior temporal quadrant 4 mm from the limbus, then a 2.2 mm clear corneal incision for cataract surgery was made at the 10-o’clock position, using a 2.2 mm ophthalmic phaco knife (MANI, Tochigi, Japan). For the side instrument, a 1.2 mm limbal incision was made at the 2-o’clock position left of the main incision using the same phaco knife. Following creation of clear corneal incision, viscoelastic material was injected into the anterior chamber.
5 mm continuous curvilinear capsulorhexis was performed with microcapsulorhexis forceps suitable for 2.2 mm incision. After hydrodissection and rotation, a stop-and-chop phacoemulsification technique was utilized for nucleus removal. The cortex was removed and the capsular bag was filled with viscoelastic material. A hydrophilic, acrylic monofocal aspheric IOL, TECNIS iTec (Abbott Medical Optics AMO, Illinois, USA), was placed in the capsular bag by docking onto the inner lip of the main clear corneal incision. The corneal wound was hydrated with balanced salt solution following removal of viscoelastic material. The valve of the preplaced trocar was removed by surgical forceps, and the high-flow infusion line of the EVA surgical system was then connected. The eye was pressurized, allowing for controlled placement of two 25-gauge vitrectomy trocars in the superior quadrants 3.5 mm from the limbus. A 27-gauge twin light chandelier was placed at 11 and 1 o’clock position (Figure
Hybrid 25-27-gauge vitrectomy setting following coaxial 2.2 mm small incision cataract surgery.
Vitreous surgery was performed using a 25-gauge TDC vitreous cutter controlled using the EVA vacuum vitrectomy unit. The vacuum level was placed at maximum 600 mmHg, and the vitreous cutter rate set at 8,000 cuts per minute (cpm). The TDC vitrectomy has a second port in the distal part of the inner pipe, which enables permanent aspiration, constant flow, and doubling of vitreous cut rate to an effective operating speed of 16,000 cpm. Vitrectomy was undertaken to achieve complete evacuation of the posterior vitreous and extensive removal of peripheral vitreous. In some patients, vitrectomy was combined with epiretinal membrane dissection and/or internal limiting membrane peeling. Fluid-air or gas exchange was performed to prevent postoperative hemorrhage and hypotonia in all cases.
Ocular surface preparation prior to surgery consisted of rinsing the conjunctival sac of the eye to be operated on with povidone-iodine and careful application of povidone-iodine via swabbing to the periocular skin of both eyes. No antibiotic agent was added to the irrigation fluid or anterior chamber. Patients received a course of topical ophthalmic corticosteroid therapy with dexamethasone together with gentamicin antibiotic treatment for between 4 weeks and 5 weeks postoperatively.
A series of prespecified primary and secondary outcome measures were analyzed retrospectively. Primary intraoperative outcome measures were leaking corneal and scleral incision requiring suturing, posterior capsule tear, conversion to larger-gauge vitrectomy, and retinal break. Primary postoperative outcome measures were IOP change, fibrin in the anterior chamber, IOL capture or decentration, posterior capsule opacification (PCO), choroidal effusions, retinal or choroidal detachment, and endophthalmitis.
Visual acuity was assessed as the main secondary outcome measure. For statistical analysis, standard Snellen measurements were converted to logarithm of the minimum angle of resolution (logMAR) values. Preoperative and postoperative logMAR visual acuities were compared using the paired two-tailed Student’s
A total of 55 patients (55 eyes) underwent combined small incision phacoemulsification, IOL implantation, and hybrid 25-27-gauge vitrectomy surgery. The average patient age was 70 years, with 23 male and 32 female subjects. The mean postoperative follow-up was 6 months (range: 2–18 months).
The most common indication for vitrectomy surgery was epiretinal membrane (26 eyes, 47.3%), followed by macular hole stage 4 (11 eyes, 20%), vitreomacular traction (6 eyes, 10.9%), and proliferative diabetic retinopathy (5 eyes, 9.1%). Internal tamponade was performed with 20% sulfur hexafluoride (SF6) or air; the decision and selection regarding tamponade procedure were based on assessment of preoperative and intraoperative clinical characteristics.
Intraoperative and postoperative findings are shown in Table
Main outcomes: intraoperative and postoperative findings.
Variable | Patients, |
---|---|
Intraoperative findings | |
Retinal break | 3 (5.5) |
Posterior capsule tear | 0 (0) |
Corneal suture | 0 (0) |
Scleral suture | 0 (0) |
Conversion to larger-gauge vitrectomy | 0 (0) |
Postoperative findings | |
Fibrin in the anterior chamber | 3 (5.5) |
Hypotony (<7 mmHg) | 0 (0) |
Elevated intraocular pressure (>30 mmHg) | 1 (1.8) |
Retinal or choroidal detachment | 0 (0) |
Endophthalmitis | 0 (0) |
Posterior capsule opacification | 7 (12.7) |
Intraocular lens capture or decentration | 0 (0) |
The preoperative IOP (mean ± SD) was
Fibrin reaction in the anterior chamber was observed in 3 eyes (5.5%) the day after surgery, which was resolved following topical steroid treatment. During follow-up, there were no cases of lOL decentration or capture, while PCO developed in 7 eyes (12.7%). There were no cases of postoperative endophthalmitis or choroidal detachment.
The preoperative logMAR visual acuity (mean ± SD) in the current case series was
In a series of 85 eyes, Canan et al. [
The present clinical study was designed specifically to evaluate the potential intraoperative and postoperative complications and visual results of a hybrid 25-27-gauge microincisional sutureless vitrectomy in combination with coaxial small incision cataract surgery, and the primary and secondary outcomes have been reported above.
None of the 55 eyes in our case series required suture of the cornea wound or sclerotomy site at the end of the surgery, and there were no serious complications related to corneal wound leakage. A similar retrospective study which evaluated combined 1.8 mm microincision cataract surgery and 23-gauge vitrectomy found corneal suturing was required in 6 of 50 eyes (12%), with a sclerotomy suture in 4 eyes (8%) [
Intraoperative complications commonly associated with pars plana vitrectomy (PPV) procedures are iatrogenic retinal breaks, lens touch, and iatrogenic retinal tears [
No case of capsule tear was observed during phacovitrectomy surgery. Treumer et al. [
There were no occurrences of postoperative hypotony in the present study. In a smaller series of 30 eyes, Moon et al. [
It was decided not to administer antibiotics to the anterior chamber at the end of the phacovitrectomy case; Delyfer et al. [
Formation of posterior synechia of the iris is a postoperative complication of combined phacoemulsification and PPV. Oh et al. [
With regard to other postoperative anterior segment complications, the rate of posterior capsule opacification over the follow-up period was 12.7% (7 eyes), which is at the lower end of the range reported from similar investigations. Posterior capsule opacification is a common postoperative anterior segment complication associated with combined phacovitrectomy, with incidence rates of up to 51% reported in the literature [
There were no cases of intraocular lens capture or decentration following combined phacovitrectomy surgery. A case series evaluation of sub-2 mm MICS combined with 23- or 20-gauge vitrectomy using an IOL with a 4-point fixation design similarly reported no cases of IOL decentration [
Visual results that were recorded in our study population are generally consistent with published outcomes from other clinical studies, demonstrating that good functional outcomes are achievable with combined hybrid MIVS and phacoemulsification using 2.2 mm microincision corneal wounds. Combining phacoemulsification, IOL implantation and vitrectomy offer clearer visualization during surgery compared with sequential procedures, and often time decreases visual rehabilitation time in cases with early or visually significant cataracts [
To summarize, surgical and visual outcomes demonstrate that a single-session approach is safe, feasible, and effective for the treatment of vitreoretinal pathology and coexisting cataract, with minimal incremental surgical risk. Additional clinical studies evaluating multicenter practice outcomes utilizing combined phacovitrectomy will help guide practitioners as they transition toward more efficient minimally invasive combination approaches for a variety of vitreoretinal pathologies with and without visually significant cataract.
Mitrofanis Pavlidis is a consultant to DORC International and declares a proprietary financial interest. None of the other authors have any conflict of interests to disclose.