SAME-DAY VERSUS DELAYED VITRECTOMY WITH LENSECTOMY FOR THE MANAGEMENT OF RETAINED LENS FRAGMENTS

MARCUS H. COLYER, MD, DANIEL M. BERINSTEIN, MD, NOUREEN J. KHAN, MD, ERIC D. WEICHEL, MD, MICHAEL M. LAI, MD, PHD, WILLIAM F. DEEGAN, MD, RESHMA C. KATIRA, MD, WILLIAM B. PHILLIPS, MD, REGINALD J. SANDERS, MD, RICHARD A. GARFINKEL, MD
Purpose: To evaluate whether performing same-day pars plana vitrectomy versus delayed pars plana vitrectomy affects visual outcomes and ocular morbidity of patients with retained lens fragments after a complicated cataract surgery. Methods: Retrospective, comparative case series of 172 eyes of 171 patients with retained lens fragments undergoing 3-port pars plana vitrectomy using 20-, 23-, or 25-gauge instrumentation between 2005 and 2008. Outcome measures included bestcorrected visual acuity at 6 months, nal best-corrected visual acuity, and postoperative complications such as cystoid macular edema, intraocular pressure elevation, retinal detachment, vitreous hemorrhage, choroidal hemorrhage, and endophthalmitis. Results: The median age was 75 6 0.8 years. The mean time to vitrectomy for the delayed group was 15 6 2 days. The preoperative logarithm of the minimum angle of resolution best-corrected visual acuity for immediate vitrectomy was 0.73 6 0.09 versus 0.72 6 0.06 for delayed vitrectomy. Six-month logarithm of the minimum angle of resolution acuity was 0.44 6 0.09 for same-day vitrectomy compared with 0.44 6 0.05 for delayed vitrectomy (P = 0.97, 2-tailed t-test). Of 59 eyes undergoing immediate vitrectomy, 17 (29%) experienced postoperative complications, while 38 of 113 eyes (34%), experienced complications if undergoing delayed vitrectomy (Fisher exact test, P = 0.61). Overall, the most common complication was cystoid macular edema occurring in 25 of 172 eyes (15%). Conclusion: The outcomes of same-day pars plana vitrectomy appear to be similar to nonsame-day pars plana vitrectomy. The risks and benets related to the timing of vitrectomy after a complicated cataract surgery should be carefully discussed with each patient. Further investigation is warranted to establish an optimal time for surgical planning. RETINA 31:15341540, 2011

etained nuclear fragments complicating cataract surgery occur at a frequency approaching 1%.15 Vitrectomy for retained lens fragments has reduced the incidence of relatively common comorbidities such as inammation, cystoid macular edema, glaucoma, and retinal detachment (RD).6,7 One surgical variable that has not been clearly dened is the timing of vitrectomy in relation to the initial complicated cataract surgery. The surgical timing of removing retained lens fragments has customarily been to delay any intervention, unless the development of severe inammation or intractable glaucoma was seen.8 Despite limited data, the possibility of same-day pars plana vitrectomy (PPV) for retained lens fragments is becoming more
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practical with the recent advancements in surgical equipment and techniques.9,10 The purpose of this study is to evaluate differences in visual outcomes, complications after same-day PPV, and the feasibility of performing same-day PPV for retained lens fragments. Methods A retrospective consecutive review was performed for patients undergoing PPV with lensectomy for retained lens fragments after complicated cataract extraction (CE) referred to a single vitreoretinal surgical practice between January 2005 and December 2008. Inclusion criteria included patients who had

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undergone primary CE complicated by dislocated lens fragments, a visual acuity of light perception or better, and follow-up of at least 6 months. Patients with ,6 months of follow-up were excluded from the study. Same-day vitrectomy was dened as patients undergoing vitrectomy within 12 hours of their cataract surgery. In most cases, patients were transferred from the operating room to a waiting area, evaluated by a vitreoretinal surgeon and consented for vitrectomy. Those undergoing nonsame-day surgery were referred to the ofce for evaluation, consented, and scheduled for elective removal. The majority of patients underwent both cataract and vitrectomy surgery at the same facility. All patients either underwent 3-port PPV via a standard 20-gauge approach or a transconjunctival sutureless 23-gauge or 25-gauge approach. If a fragmatome was used in smaller-gauge cases, a 20-gauge temporal sclerotomy was extended through the previous smaller-gauge sclerotomy to facilitate access. No patients required surgical adjuvants such as peruorocarbon liquids or viscoelastics. The following variables were collected for each patient: age, eye, gender, visual acuity before cataract surgery, size of lens fragment, type of lens implant, preexisting ocular disease, vitrectomy gauge, use of fragmatome, complications, and nal vision. Visual acuity was measured by standard Snellen eye charts and converted to logarithm of the minimum angle of resolution for the purpose of statistical analysis. Best-corrected visual acuity was recorded when possible. Pinhole measurements were recorded when patients had residual refractive error after surgery. Results This study included 172 eyes of 171 patients with a median age of 75 6 0.8 years. Fifty-nine patients underwent same-day PPV while 113 people underwent nonsame-day PPV. Sixty-ve patients underwent 20-gauge PPV, 32 patients underwent 23-gauge PPV, and 75 patients underwent 25-gauge PPV. Phacofragmentation was required in 126 cases (55

From The Retina Group of Washington, Chevy Chase, Maryland. Presented at the following meetings: Lecture at the Retina Congress, New York City, NY, October 3, 2009; poster at the Annual Meeting of the Academy of Ophthalmology, San Francisco, CA, October 25, 2009; and poster at the American Society of Retina Specialists, Vancouver, Canada, August 30, 2010. R. A. Garnkel is a consultant to Eyetech. R. J. Sanders is a consultant to Genentech. The other authors have no conicts of interest to disclose. Reprint requests: Marcus H. Colyer, MD, Retina Group of Washington, 10530, Linden Lake Plaza #305, Manassas, VA 20109; e-mail: colyer_m@yahoo.com

required 20 gauge, 23 required 23 gauge, and 48 required 25 gauge). Of patients undergoing immediate vitrectomy, 51 of 59 eyes (86%) required phacofragmentation while 72 of 113 eyes (64%) in the delayed group required phacofragmentation at the time of vitrectomy. Mean preoperative logarithm of the minimum angle of resolution visual acuity was 0.73 6 0.09 in the same-day group and 0.72 6 0.06 in the non same-day group (P = 0.90, 2-tailed t-test). Refer to Table 1 for preoperative characteristics of both groups. For the purposes of this analysis, preoperative refers to precataract surgery vision. In the nonsame-day group, 18 patients (16%) presented on maximal medical therapy after cataract surgery with an intraocular pressure of .30 mmHg. The median time to surgery in the nonsame-day group was 7 days with a mean time of 15 days. There was no statistically signicant difference between the two groups. If evaluating according to the surgical variables, the median size of retained lens fragment was graded according the following scale: 1 (cortical fragments only), 2 (,1/2 nucleus), and 3 (.1/2 of nucleus). Of 28 large nuclear fragments, 46% were removed immediately while 54% the next day or thereafter. Conversely, of 52 cases involving only cortical fragments, 21% were removed immediately, while 79% were removed in a delayed fashion (Pearson x1, P = 0.033). Thus, there was a trend toward smaller fragments being removed in a delayed fashion and larger fragments being removed immediately. Similarly, large nuclear fragments were removed using 20-gauge instrumentation in 54% of cases, while microincisional instruments were used in 46% of cases. Cortical fragments, rather, were removed using smallgauge instruments in 79% of cases, while 20-gauge instruments were used in only 21% (Pearson x1, P = 0.006). Also, the mean days to surgery in the largegauge group was 8.1 6 1.9 days and in the small-gauge group was 11.2 6 2.3 days (P = 0.35, paired t-test). The overall 6-month logarithm of the minimum angle of resolution was 0.44 6 0.09 in the sameday group and 0.44 6 0.05 in the delayed group (P = 0.97) (Table 2). Visual outcomes were similar when comparing small-gauge with large-gauge vitrectomy (Table 3). Forty-two patients (71%) achieved $20/40 visual acuity at 6-month follow-up in the same-day group versus 73 patients (65%) in the non same-day group. If patients with preexisting ocular disease (such as advanced glaucoma, macular degeneration, or diabetic retinopathy) are excluded from visual acuity analysis (n = 52), 6-month logarithm of the minimum angle of resolution was 0.22 6 0.07 in the same-day group and 0.27 6 0.04 in the delayed group (P = 0.56).

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Table 1. Preoperative Characteristics of Patients Undergoing PPV for Retained Lens Fragments Same Day Number of patients Age (years) Male/female Right eye/left eye Preexisting ocular disease Preoperative intraocular pressure Median number of preoperative eye drops Preoperative logMAR Previtrectomy logMAR Average time to surgery (days)
*Two-tailed t-test. Chi-square test for independence. logMAR, logarithm of the minimum angle of resolution.

Delayed 113 73.2 6 1.0 55/58 50/63 33 22.6 6 1.5 ,1 0.72 6 0.06 1.23 6 0.09 15 6 4

P 0.05* 0.88 0.21 0.68 0.90*

59 76.5 6 1.3 28/31 32/27 19 0.73 6 0.09

Complication rates were similarly distributed in the 2 groups with 17 patients (29%) experiencing complications in the same-day group and 38 patients (34%) experiencing complications in the nonsameday group (Table 4). Complication rates were similar when considering gauge of instrumentation as well (Table 5). Visual outcomes in those experiencing complications were worse than those without complications, but not statistically signicantly different (0.41 vs. 0.41, respectively, P = 0.97). Three patients with vision ,20/200 (17%) had vision loss because of complications after vitrectomy, 2 patients (11%) suffered vision loss secondary to bullous keratopathy, while 13 patients (72%) had limited vision secondary to preexisting ocular disease, such as advanced glaucoma, macular degeneration, or diabetic retinopathy. After surgery, 3 patients (5%) developed ocular hypertension in the same-day group versus 5 patients (4%) in the nonsame-day group. Two patients presented with signs/symptoms of endophthalmitis after nonsame-day vitrectomy

(to include hypopyon, vitritis, and pain). Both cases demonstrated culture positivity for Staphylococcus epidermidis. Both the endophthalmitis cases were with 25-gauge instrumentation, unbeveled, sutureless, and the eyes were left uid lled. Both patients had undergone vitrectomy .1 week after the initial CE. Retinal detachment developed in 6 patients (3%). Fragmatome was used in 5 of 6 cases in which RD developed. Two cases followed 20-gauge instrumentation, 3 cases followed 25-gauge surgery, and 1 case followed 23-gauge instrumentation. One patient (1%) developed RD after CE. Retinal detachment repair was performed in ve of six patients while one patient deferred further treatment. Of the ve patients undergoing subsequent detachment repair, four underwent vitrectomy with scleral buckle and one underwent vitrectomy with silicone oil. Five patients required only one surgery while one patient required two surgeries. All six were attached at nal follow-up.

Table 2. Visual Acuity Outcomes of Patients Undergoing PPV with Lensectomy Same Day All patients 6-month vision (logMAR) Percent of patients achieving $20/40 Percent of patients with vision #20/200 Exclude preexisting ocular disease 6-month vision logMAR) Percent of patients achieving $20/40 Percent of patients with vision #20/200
*Two-tailed t-test. Chi-square test for independence. Fisher exact test for independence. logMAR, logarithm of the minimum angle of resolution.

Delayed 113 0.44 6 0.05 65% 11% 74 0.27 6 0.04 81 7

P 0.97* 0.38 0.02 0.56* 0.18 0.43

59 0.44 6 0.09 71% 20% 42 0.22 6 0.07 90 5

IMMEDIATE VITRECTOMY FOR RETAINED LENS  COLYER ET AL Table 3. Visual Acuity Outcomes of Patients Undergoing PPV with Lensectomy 20 Gauge 23/25 Gauge P

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All patients 63 105 6-month vision 0.36 6 0.06 0.43 6 0.06 0.38* (logMAR) Percent of patients 71 68 0.60 achieving $20/40 Percent of patients 14 19 0.63 with vision #20/200
*Two-tailed t-test. Chi-square test for independence. logMAR, logarithm of the minimum angle of resolution.

Discussion The optimal timing of PPV for retained lens fragments after CE continues to be debated. Numerous factors contribute to timing, including media clarity, degree of ocular inammation, the location of the patient in relation to the vitreoretinal specialist and/or surgical facility, and previously published data discussing visual outcomes. In our population, same-day surgery is performed when clinically indicated and logistically advantageous for the patient. The intent of the study was to compare outcomes to determine whether visual outcomes signicantly differed between these two groups. Visual outcomes and complication rates of patients undergoing same-day versus nonsame-day vitrectomy were comparable in this study, with an overall mean logarithm of the minimum angle of resolution of 0.41. A recent unpublished report suggested that the average visual outcome in patients undergoing immediate vitrectomy was 20/30. In our population, when patients with preexisting ocular disease (n = 52) are excluded, visual outcomes approach 20/30, while patients undergoing delayed surgery were slightly better than 20/40. These results, however, are not statistically signicantly different. To detect a 1-line difference in visual acuity (20/30 vs. 20/40) in patients without preexisting ocular disease, a prospective comparative study would require 204 patients to be enrolled in each subgroup to detect a difference with 95% condence at an 80% power level. Furthermore, there appears to be no signicant difference in visual outcomes when considering surgery within 7 days of original cataract surgery or .7 days. Similar to these ndings, complication rates do not signicantly differ between the groups. Several features of this study require comment. As mentioned, the possibility of performing same-day vitrectomy for retained lens fragments has become

a reasonable treatment alternative despite a paucity of literature supporting its use. The timing of vitrectomy requires careful discussion between the patient, family, cataract surgeon, and vitreoretinal surgeon. In particular, if same-day vitrectomy is considered, careful informed consent must be rendered. Patients and families are often appreciative when same-day vitrectomy can be performed as it avoids additional trips to the operating room, and reduces risks associated with repeated anesthesia. Furthermore, the problem is managed immediately. A potential benet of having the capacity to perform same-day vitrectomy is that the fewer aggressive attempts at rescuing dislocated lens fragments will be made by the cataract surgeon, reducing the likelihood of collateral damage to intraocular structures.7,1116 The authors anecdotally note that when same-day vitrectomy capability is available, cataract surgeons are quicker to refer patients for denitive management. Conversely, performing same-day vitrectomy has potential pitfalls such as reduced visualization through an edematous cornea, hypotony, intraocular inammation, suprachoroidal hemorrhage, serous choroidal detachment, and patient fatigue from multiple surgeries. There are several important considerations when choosing instrumentation during retained lens surgery. First, infusion mismatch is more prominent during small-gauge vitrectomy, particularly when the use of the fragmatome is required.17 Further, the size of the vitrectomy port with smaller-gauge vitrectomy may necessitate the use of phacofragmentation in more instances. Additionally, the placement of trocars in small-gauge vitrectomy may be complicated by chamber shallowing with the risk of lens dislocation

Table 4. Complication Rates Between Subgroups of Patients Undergoing PPV Same Day Overall complications Cystoid macular edema Macular pucker Intraocular pressure elevation (.30 mmHg postoperatively) Hypotony RD Choroidal hemorrhage Endophthalmitis IOL dislocation (late) Preexisting ocular diseases excluded
*Fisher exact test. Chi-square test.

NonSame Day 38 (32%) 15 9 5 4 2 3 2 3 38 (30%)

P 0.66* 0.17* 0.48* 1.00* 0.66* 0.18* 1.00* 0.54* 0.41* 0.24

17 (29%) 8 3 3 1 4 2 0 3 14 (33%)

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Table 5. Complication Rates Between Subgroups of Patients Undergoing PPV 20 Gauge Overall complications (immediate/delayed vitrectomy) Cystoid macular edema (immediate/delayed vitrectomy) Macular pucker (immediate/delayed vitrectomy) Intraocular pressure elevation (.30 mmHg postoperatively) (immediate/delayed vitrectomy) Hypotony (immediate/delayed vitrectomy) RD (immediate/delayed vitrectomy) Choroidal hemorrhage (immediate/delayed vitrectomy) Endophthalmitis (immediate/delayed vitrectomy) IOL dislocation (late) (immediate/delayed vitrectomy) Preexisting ocular diseases excluded (immediate/delayed vitrectomy)
*Chi-square test for independence. Fisher exact test.

23/25 Gauge 31 11 6 6 1 4 3 2 5 22 (29%) (10/21) (2/9) (1/5) (3/3) (1/0) (2/2) (1/2) (0/2) (2/3) (30%) (8/14)

P 0.39* 0.16 0.37 0.71 0.07 1.00 1.00 0.52 0.16 0.59*

22 12 6 2

(35%) (7/15) (6/6) (2/4) (0/2)

4 (0/4) 2 (2/0) 2 (1/1) 0 (0/0) 0 (0/0) 15 (34%) (6/9)

because of cataract wound construction and/or absence of corneal sutures. However, the use of small-gauge instrumentation limits conjunctival scarring, which may be an important consideration, because eyes after complicated cataract surgery with retained lens fragments may be at increased risk for glaucoma.18 One advantage when using small-gauge instrumentation for retained lens fragments is the ability to insert the vitreous cutter tip into the anterior chamber through a small self-sealing paracentesis. This enables the surgeon to remove residual cortical material in the anterior chamber and remove prolapsed or incarcerated vitreous. This capability is particularly useful with 25-gauge instrumentation. With the transition to small incision cataract surgery, such a technique may be helpful in achieving a rapid visual recovery. Thus, surgeons may consider the use of smaller instrumentation when more anterior chamber ndings are revealed during preoperative evaluation, regardless of the size of retained lens fragments in the anterior chamber. The rates of RD in this study are similar to rates found in other studies.7,1925 One concern when performing same-day vitrectomy is the inability to visualize small peripheral retinal breaks after a complicated CE, whose incidence approaches 5%.19 However, we found no difference in outcomes in this series when considering same-day and delayed vitrectomy. No peripheral breaks were identied during the initial vitrectomy and the median time to detachment after vitrectomy in our series was 3 months. Only one patient developed a RD within 1 month of lensectomy. All other cases occurred with a median time to detachment of 3 months. This would suggest that new retinal breaks rather than unrecognized breaks would account for these ndings. It should be noted that most patients who developed RD had undergone phacofragmentation with the

fragmatome. Such ndings have been published previously.26,27 It is unknown whether the use of the fragmatome was associated with the development of RD, or it is possible that RD resulted from vitreous traction related to a larger amount of dislocated lens material occurring during the initial cataract surgery. In this series, only one patient had a RD preoperatively. This low rate of RD after complicated CE may be attributed to less surgical manipulation during the initial cataract surgery. The late development of RD as an event remote from the initial vitrectomy is an interesting feature in our series. It has previously been recognized that complications such as posterior capsule tear and anterior vitrectomy during CE predispose to earlier development of RD.28 One additional study29 of pseudophakic RDs demonstrated a mean time to RD after vitrectomy for retained lens fragments as 3.8 months as compared with 15 months for patients without retained lens fragments who subsequently detached. A similar review of eyes undergoing RD repair after vitrectomy noted that RD occurred within 1 month of surgery in only 25% of patients, while nearly 50% of patients detached 3 months after surgery or beyond. Both series had similar follow-up intervals as this review.22 Presumably, during the initial vitrectomy, an incomplete vitreous detachment allowed for the development of retinal tear formation at a subsequent time. Alternatively, the retinal breaks associated with late-onset RD were present at the time of initial vitrectomy, but subretinal uid accumulation occurred only after several weeks or months of time. Our series demonstrates similar timing relationships to the original vitrectomy as those previously published. Results of use of phacofragmentation with smallgauge vitrectomy systems have not previously been reported. Conversion of one of the sclerotomy ports to a 20-gauge incision is simple in this series and it did

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seem to increase the risk of retinal tears or detachments. Intraoperatively, however, infusion pressure must be raised to maintain adequate infusion during phacofragmentation. Closure of the sclerotomy requires the placement of a single suture, and postoperative outcomes mirror those of 20-gauge surgery. Endophthalmitis after surgery for retained lens fragments is an infrequent event. However, the risk of endophthalmitis may be higher in this population.30,31 Additionally, numerous authors have noticed an association between small-gauge vitrectomy and postoperative endophthalmitis.3235 Both cases of endophthalmitis in this series had used 25-gauge instrumentation. Additionally, the patients underwent vitrectomy .7 days after the original surgery, had unbeveled, sutureless incisions, and were left with a complete uid ll. These factors may have contributed to the increased risk of postoperative endophthalmitis. The development of glaucoma did not appear to be inuenced by the timing of vitrectomy in this retrospective series. In a small subgroup of patients with longer-term follow-up (n = 86), only 6 patients subsequently developed glaucoma (7%). One patient had undergone same-day vitrectomy while 5 patients had undergone nonsame-day surgery (P = 0.20, Fisher exact test). It is important to note that there were some differences in the preoperative characteristics of the groups in lens fragment size. As noted in the results, larger fragments tended to be removed sooner in this study (46% immediate vs. 53% delayed) as opposed to small fragments (21% immediate vs. 79% delayed). Additionally, small-gauge instrumentation tended to be used to remove smaller lens fragments (78% of all cortical fragments vs. 53% of all nuclear fragments). Given the hypothesis that larger nuclear fragments are likely to promote more inammation and cause more injury during removal, one cannot equate the outcomes without factoring these variables. The most signicant feature of these confounding variables is that visual outcomes may be slightly skewed toward better outcomes in those patients undergoing smallgauge vitrectomy given that these eyes generally had smaller retained lens fragments. Despite the retrospective nature of this study, our data suggest that there is no signicant difference in outcomes between patients undergoing vitrectomy surgery on the same day as cataract surgery or on a different day from the original cataract surgery. Overall, mean visual outcome was 20/40, while .71% of patients achieved a nal visual outcome of 20/40 or better. Similarly, complication rates between the two groups were not statistically different.

Conclusions Given that visual outcomes and complication rates were similar between the two groups, it is reasonable to consider vitrectomy on the same day as cataract surgery. Our data demonstrate no detriment with delayed vitrectomy, either. Thus, vitreoretinal surgeons should consider same-day vitrectomy when medically and/or logistically advantageous. This study is limited as it is a retrospective, multisurgeon, review of outcomes after vitrectomy surgery. Limited longterm data are available. Additionally, the varied surgical techniques used by the various surgeons may also confound our data. However, this is the largest study to date analyzing the outcomes of sameday PPV in the management of retained lens fragments. Our data suggest that the decision of timing of surgery is multifactorial. The surgeon must determine the most appropriate timing of surgical intervention based on the location of the patient, the availability of the surgical facility, the surgeons own availability, and the suspected degree of ocular complications, which may be encountered during the denitive procedure. Key words: retained lens fragments, pars plana vitrectomy, cataract surgery complications, cataract, pseudophakic, 20-gauge vitrectomy, 23-gauge vitrectomy, 25-gauge vitrectomy, same-day vitrectomy.

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