Tan A, Bertrand-Boiché M, Angioi-Duprez K, Berrod J, Conart J. Outcomes of Combined Phacoemulsification and Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment: A Comparative Study. Retina 2021; 41:68-74.
For the majority of retina surgeons, pars plana vitrectomy (PPV) has become the preferred technique to repair primary rhegmatogenous retinal detachments (RRD), even in phakic patients. If logistically feasible, some surgeons opt to perform cataract surgery at the same time as vitrectomy. Are there any advantages to performing combined cataract surgery and PPV versus staging the procedures? The authors here compare anatomical and functional results of both options and evaluate the refractive outcomes.
In this retrospective comparative case series performed at a single site in France, only phakic patients with primary RRD were included and required 6 months of follow up after surgery. Any eyes with grade C proliferative vitreoretinopathy (PVR), underlying macular pathology, history of trauma or prior refractive surgery were excluded. The determination to perform combined cataract surgery with PPV was made by the surgeon depending on the lens opacity and patient’s age. All eyes underwent 23 or 25 gauge PPV with endolaser or cryotherapy and gas (either 25% SF6 or 20% C2F6/air mixture). For the combined cases, phacoemulsification was performed first followed by the PPV.
A total of 117 eyes underwent combined phaco and PPV while 139 underwent PPV alone. Patients in the combined surgery group (66.3 years) were significantly older by an average of 11 years compared to the PPV alone cohort (55.3 years). There was no significant difference between the two groups in the pre-operative axial length, duration of RD prior to surgery, extent of RD, macular status, vitreous hemorrhage, PVR grade or type of gas tamponade. Both groups had excellent anatomical success rates (84.3%, 89.2%) and complete retinal reattachment (94.5%, 95.7%). There were minimal complications in both groups that were not significant. While both groups had improvement in visual acuity, there were more visual acuity gains in the combined group, though the difference was not statistically significant. After accounting for the eyes in the PPV only group that later underwent cataract surgery (delayed group), there was no significant difference in the final BCVA or mean visual change. The most notable difference between the two groups was the myopic shift in the combined group (-0.32 ± 1.28D) compared to the delayed group (0.16 ± 1.53D) in macula-off RD, which was statistically significant.
The authors concluded that combined cataract surgery with PPV for primary RRD in phakic patients is a safe and effective procedure with anatomical success. The biggest advantage of performing combined cataract surgery with PPV is shortened delay for visual recovery. Other advantages include less cost to patient, better vitreous base dissection, and more complete gas fill. However in macula involving RRD, the pre-operative axial length measurements may be underestimated and result in myopic shift. The authors recommended performing both optical and A-scan ultrasound biometry and selecting the longer ultrasound-measured-AL for calculating the IOL power.
While the theoretical disadvantages of performing combined surgery include longer surgical time, loss of corneal transparency, increased risk of posterior synechiae and possible IOL capture or dislocation, no significant increase in complications between the two groups was reported in this study. The authors acknowledged the limitations of retrospective design and the inherit selection bias of the surgeon deciding whether or not to perform cataract surgery with PPV. A randomized prospective comparative series could further strengthen / corroborate the findings of this paper.
Overall this study provides helpful considerations when deciding to perform combined cataract surgery and PPV versus PPV with delayed cataract surgery.
Jaya B. Kumar, MD
Florida Retina Institute