Thur_Pioneer_1450_Peter Simcock

Combined phacovitrectomy
Peter Simcock FRCP FRCS FRCOphth
West of England Eye Unit
Exeter
SHO MREH 1987
“Beautiful ECCE’s”
Registrar MREH 1990 - 1992
Phaco “being tried” at MREH
“Unlikely to catch on”
Senior Registrar Charing Cross and
Moorfields 1993 - 1995
SHO taught me Phaco!
“Phaco is the way to go”
VR Fellow MREH 1995 -1996
Fantastic training in VR
Post vitrectomy cataract sent to anterior segment team
Vitrectomy and cataract
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Nuclear sclerosis
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Formed gel protective
Increased in myopia
Increased post vity
Gradual onset
Gas cataract
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Large gas fill
Posterior sub capsular
Immediate effect
Patient perspective
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Has “big” vitreoretinal operation in hospital
May need to posture post op
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Uncomfortable
Develops index myopia
Change in glasses
 Change in glasses
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Referred back to hospital
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Back in for cataract operation
Surgeons perspective
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Difficult cataract surgery
Lens / zonules damage
 High myopes
 A/C instability and variable pupil size
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BUT
Modern phaco machines have better A/C
stability
 Ways of avoiding iris bounce
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Szijarto Z et al Phacoemulsification on previously
vitrectomized eyes: Results of a 10-year-period. Eur
J Ophthalmol. 2007 Jul-Aug;17(4):601-4
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143 eyes
Per-op
 93% deep or fluctuating A/C depth
 9% PC rupture
 5% incomplete capsulorhexis
Post-op
 6% retinal detachment
Sunderland Eye Infirmary
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Ghosh S et al. Lens – iris diaphragm retropulsion
syndrome during phacoemulsification in
vitrectomized eyes J Cataract Refract Surg 2013
Dec 39(12):1852-8
Case series of 75 eyes
 53% had evidence of iris diaphragm retropulsion
syndrome
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Cataract National Dataset electronic multicentre
audit of 55,567 operations: risk stratification for
posterior capsule rupture and vitreous loss
Eye 2008
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Age
Male gender
Glaucoma
Diabetic retinopathy
White cataract
Poor fundal view
Phacodonesis / PXF
Small pupil
Axial length >26mm
Inability to lie flat
Trainee surgeon
Use of alpha blocker
Private practice perspective
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Some people may not be so keen on
combined surgery!
Combined surgery – historical
perspective
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If no cataract, leave lens and do vitrectomy
alone
If mild cataract but good view of fundus, leave
lens and do vitrectomy alone
If sufficient cataract to impair fundal view, do
vitrectomy and lensectomy (posterior approach
to lens)
Lens in sulcus if sufficient capsule support
 AC IOL if insufficient capsule support
 May require large corneal section
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Combined surgery – with advent of
good phaco technique
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If no cataract, leave lens and do vitrectomy
alone
If mild cataract but good view of fundus, leave
lens and do vitrectomy alone
If sufficient cataract to impair fundal view, do
phaco vitrectomy (anterior approach to lens)
Lens in capsular bag
 Small corneal section
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Why not routinely remove the lens in
a presbyopic patient undergoing
vitrectomy?
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Lens already lost ability to accommodate
Cataract formation almost inevitable after
vitrectomy
Avoid patient having to return for further
surgery
Possibility of emmetropia
1997 Exeter
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Keen newly appointed consultant
Why not do phaco vitrectomy on presbyopic
patients?
Would also enable more complete vitrectomy
Would also enable very large gas fills with no
worries about gas cataract
Perhaps would not need to posture for patients
having surgery for macula hole?
Tornambe PE et al. Retina, 1997;17(3):179-85. Macular hole
surgery without face-down positioning
Simcock PR, Scalia S. Acta Ophthalmol Scand. 2000
Dec;78(6):684-6 Phaco-vitrectomy for full-thickness macular
holes.
Simcock PR, Scalia S. Br J Ophthalmol. 2001
Nov;85(11):1316-9. Phaco-vitrectomy without prone posture
for full thickness macular holes. (71 citations)
Exeter macular hole study
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Combined phaco-vitrectomy surgery
With posture
 Without posture
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13 patient
20 patients
Results
With posture
 Without posture
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85% hole closure
90% hole closure
“The whole is greater than the
sum of it’s parts”
From Zen Buddism
Ling R, Simcock P et al. Presbyopic phacovitrectomy.
Br J Ophthalmol. 2003 Nov;87(11):1333-5.
90 eyes (28 RRD, 44 macular holes, 11 ERM, 7
other)
13% fibrinous uveitis
1% IOL / pupil capture
Smith M, Raman SV, Pappas G, Simcock P, Ling R, Shaw
S. Phacovitrectomy for primary retinal detachment repair
in presbyopes.
Retina. 2007 Apr-May;27(4):462-7.
93 eyes, 88% reattachment rate with one op
16% fibrinous uveitis
8% IOL / pupil capture
How to avoid IOL / pupil capture
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Nothing new – keep capsulorhexis size
smaller than the optic
Avoid strong post-operative mydriatics
Tropicamide nocte for 1 week
Rahman R, Rosen PH. Pupillary capture after combined management of
cataract and vitreoretinal pathology. J Cataract Refract Surg 2002;28:16071612
How to avoid fibrinous uveitis
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Anterior chamber stability = minimal inflammation
Be aware of pressures on either side of posterior
capsule at all time
Be aware of infusion pressures and if infusions are
on or off
Pred forte 2hrly for 2 days then q.i.d.
Endo laser rather than cryo
DO NOT ALLOW ANTERIOR CHAMBER TO
COLLAPSE
Recent developments
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Better phaco machines
Good AC stability
 Microincision phaco / Bimanual phaco
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Better vitrectomy machines
Good pressure control
 Designed for combined surgery
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23g vitrectomy
Less inflammation
 Less entry site breaks
 Valved trocars to maintain pressure
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Manchester Royal Eye Hospital
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Dhawahir-Scala FE et al. Retina 2008 Jan
28(1):60-5
To posture or not to posture after macular hole
surgery
 28 eyes
 One first night of face down posture
 No need to posture if > 70% gas fill on first post op
day
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Manchester Royal Eye Hospital
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Jalil A et al. Eye 2014 Apr 28(4):389-9
Microincision cataract surgery combined with
vitrectomy: a consecutive case series
 52 eyes with 1.8mm microincision (MICS) cataract
surgery and vitrectomy
 2 eyes “significant inflammation”
 No lens decentration
 Conclusion – “safe technique”
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Current technique
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Insertion of 23g trocars
Corneal incision (no sutures)
Phaco and IA
Vitrectomy
IOL insertion
Gas (if needed)
Current practice
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Macular holes
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Retinal detachment
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Slightly increased risk of PVR
May be difficult to get accurate biometry
Vity only
Epiretinal membrane
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Phaco vity on everyone
Only posture large holes
Phaco vity on nearly everyone
Diabetes
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Vity only
Increased risk of inflammation, rubeosis,