Combined phaco-

vitrectomy

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

Nuclear sclerosis

Formed gel protective

Increased in myopia

Increased post vity

Gradual onset

Gas cataract

Large gas fill

Posterior sub capsular

Immediate effect

Patient perspective

Has “big” vitreoretinal operation in hospital

May need to posture post op

Uncomfortable

Develops index myopia

Change in glasses

Change in glasses

Referred back to hospital

Back in for cataract operation

Surgeons perspective

Difficult cataract surgery

Lens / zonules damage

High myopes

A/C instability and variable pupil size

BUT

Modern phaco machines have better A/C

stability

Ways of avoiding iris bounce

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

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

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

Cataract National Dataset electronic multicentre

audit of 55,567 operations: risk stratification for

posterior capsule rupture and vitreous loss

Eye 2008

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

Some people may not be so keen on

combined surgery!

Combined surgery – historical

perspective

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

Combined surgery – with advent of

good phaco technique

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

Why not routinely remove the lens in

a presbyopic patient undergoing

vitrectomy?

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

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

Combined phaco-vitrectomy surgery

With posture 13 patient

Without posture 20 patients

Results

With posture 85% hole closure

Without posture 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

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;28:1607-

1612

How to avoid fibrinous uveitis

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

Better phaco machines

Good AC stability

Microincision phaco / Bimanual phaco

Better vitrectomy machines

Good pressure control

Designed for combined surgery

23g vitrectomy

Less inflammation

Less entry site breaks

Valved trocars to maintain pressure

Manchester Royal Eye Hospital

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

Manchester Royal Eye Hospital

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”

Current technique

Insertion of 23g trocars

Corneal incision (no sutures)

Phaco and IA

Vitrectomy

IOL insertion

Gas (if needed)

Current practice

Macular holes Phaco vity on everyone

Only posture large holes

Retinal detachment Slightly increased risk of PVR

May be difficult to get accurate biometry

Vity only

Epiretinal membrane Phaco vity on nearly everyone

Diabetes Vity only

Increased risk of inflammation, rubeosis,