JOURNAL

COMPARISON OF POSTOPERATIVE REFRACTIVE

OUTCOME IN EYES UNDERGOING
COMBINED PHACOVITRECTOMY VS CATARACT
SURGERY FOLLOWING VITRECTOMY
Paris G. Tranos, Bruce Allan, Miltiadis Balidis, Athanasios
Vakalis, Solon Asteriades, George Anogeianakis

Presenter: Andi Ayu Lestari

Advisors :
Comentator:
Dr.dr. Habibah S. Muhiddin, Sp. M(K)
Moderator
dr. Andi Muhammad Ichsan, Ph.D, Sp.M(K)
dr. Ririn Nislawati, Sp.M, M.Kes
dr. Hamzah, Sp.M (K)
dr. Dyah Ayu Windy, Sp.M
Makassar, th Sept 2021
Zoom Meeting Department of Ophtahlmology,
Hasanuddin University
Content
01 Abstract

02 Journal Theory
03 Introduction

04 Methods
05 Results

06 Discussion
07 Conclusion
 Abstract

Wu P, Duan F, Luo C, et al. Characteristics of Ocular Findings of Patients With Coronavirus Disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020;138(5):575–578.
02. Journal Theory
MACULAR HOLE
MACULAR HOLE
Defect of the foveal retina involving
its full thickness from the internal
limiting membrane (ILM) to the ETIOLOGY:
outer segment of the photoreceptor
layer • perifoveal vitreous
detachment (PVD)
• vitreous macular
adhesion (VMA),
• High Myopia
• Unknown

Full-thickness macular hole showing a

surrounding cuff of subretinal fluid.

(Theng, 2020)
CLASSIFICATION

(Gass, 1995)
MACULAR HOLE
 COMBINED PHACOVITECTOMY

The combination of
phacoemulsification and
vitrectomy into 1 procedure Useful procedure in
patients with a range of
vitreoretinal disorders
concomitant with visually
significant cataract
During the combined
procedure, the cataract
surgery is usually
performed before PPV. When the cataract is
mild or nonexistent 
usually perform PPV
Important have a biometry only
calculation of the
intraocular lens
preoperatively
 COMBINED
PHACOVITECTOMY
 CATARACT SURGERY FOLLOWING VITRECTOMI

significantly
improves visual
acuity in 85% of
cases

Complication:
posterior capsule
opacification
or refractive
errors

Contents Limited by retinal

Title comorbidity and
surgical
complications

(Esteban, 2020)
03. Introduction
INTRODUCTION

IMPORTANT TO:
PPV combined with Investigated the accuracy of
phacoemulsification and MH and ERM still preoperative biometry in
IOL implantation has expected to have cataract
combined phacovitrectomy
become a common, and surgery as a sequential and compared it cataract
safe procedure procedure. surgery following vitrectomy

This combination procedure The combined and the

have single recovery period sequential procedure
and it offers immediate result in less accurate
visual rehabilitation and is refractive outcomes
cost-effective
02. Journal Theory
 PATIENTS AND METHODS

Study
Thype Location Sample Sampling

Retrospective Ophthalmica Eye All reported operations Total Sampling

Study Institute in Thessaloniki combined
Greece phacovitrectomy or
cataract surgery following
vitrectomy
2015 and 2017
 CLINICAL DATA
Procedure 109 eyes of 109 patients
• There was no clinically significant cataract
PPV for full-thickness MH repair or removal
 sequential surgery
of epiretinal membrane
• Patient decline  combined
phacovitrectomy

The criteria for combined phacovitrectomy

1. Presence of clinically significant lens
opacities
2. The inability of the patient to undergo
sequential surgery.
Divided 2 Group
• Phacovitrectomy (group 1, 55 eyes)
• Cataract surgery after PPV (group 2, 54
eyes).
 PROCEDURE
RFK Topcon K38800 Auto
Slit lamp
Refracto-Keratometer Axial length was measured
biomicroscopy and
to measure SE and using an optical biometry
intraocular pressure
keratometric values Lenstar 9000 Alegro
measurement
preoperatively and 1 month Biograph
postoperatively

1 2 3 4 5 6

Biometric calculations Analysis using an absolute

MH or ERM was
of IOL power using the biometry PE, with an
confirmed by OCT
SRK/T formula. achieved refraction
refraction within ± 0.5
diopter (D)
STATISTICAL ANALYSIS

DATA
• Mean ± SD for continuous variables
• Percentages for categorical variable CORRELATION
Pearson’s bivariate
NORMALITY
Kolmogorov-Smirnov test
MULTIVARIATE
• Binary logistic regression
BIVARIATE
• Odds ratio with corresponding 95% CI
Unpaired Student’s t-test or Mann-Whitney test

SPSS level of
software significance
version 17 5%
SURGERY
COMBINED PPV AND CATARACT SURGERY

01 Preparation
Three 25-gauge trocars were preplaced, plugged
in a 3.5 mm from the limbus

02 Standard Phacoemulsification
Through a 2.2 mm clear corneal incision.

03 Curvilinear Capsulorrhexis
With a diameter smaller than the optic
of the IOL

04 Implantation IOL
Two different acrylic IOLs with an optic
diameter of 6.0
02. Journal Theory
RESULT Table 1 Data summary of characteristics of patients
undergoing combined phacovitrectomy or cataract surgery
following vitrectomy (109 eyes of 109 patients)
RESULT 0.59 D
(range − 2.5 to + 1.4 D)

A significant visual improvement since best-corrected visual acuity (BCVA) for the whole group
improved from 0.62 (0.33) prior to surgery to 0.29 (0.31) at the time of postoperative refraction,
2 months following surgery (p < 0.01)
0.35 D
(range − 1.45 to + 1.0 D)

Fig. 1 Scatter plot demonstrating postoperative refractive

prediction error (PE) following combined phacovitrectomy
(group 1) and sequential cataract surgery after pars plana
vitrectomy (group 2)
RESULT
Table 2 Postoperative refractive prediction error in the study
groups

Deviation >0.5 D in the combined surgery group

Postoperative refractive deviation >1 D was
associated with shallower ACD (p = 0.011) and Independent t-test analysis
observed 10/55 eyes (18%) in group 1 and in
increased central macular thickness (CMT) (p =
3/54 eyes (5.6%) in group 2 (p = 0.073). Showed a statistical significance
0.04).
(p = 0.01)
In the sequential surgery group  associated
with worse BCVA at baseline (p = 0.013) and
shallower ACD (p = 0.007).
RESULT
age, preoperative intraocular pressure, IOL power, Not correlated (p > 0.05) with
the use of gas tamponade, or ocular parameters postoperative refractive
deviation

Not associated with

ELM, ellipsoid, or RPE disruptions significantly larger postoperative
refractive errors

Postoperative deviation Only a trend (p = 0.09) for a

postoperative deviation > 0.5D when
in MH
ELM was disrupted

Multivariate
Logistic Regression Model
Baseline BCVA, anterior chamber depth,
and central macular thickness above 300 μ
are independent risk factors of PE > 0.5D.
02. Journal Theory
 DISCUSSION

In vitrectomized eyes, cataract progresses Refractive shift (Myopia) frequently seen in

six times faster compared to fellow nonsurgical combined phacovitrectomy or cataract surgery in
eyes (Chaudhry, 2003) vitrectomized eyes (Schweitze, 2008)

• Cataract surgery in this setting results in

postoperative refractive errors A myopic shift, among both phakic (− 1.60 D) and
• Vitrectomized with phacoemulsification pseudophakic (− 0.59 D) patients (Migueal, 2018)
prone to refractive deviations (Treumer , 2006)
 DISCUSSION
Factors have been implicated in the postoperative
refractive deviation
Dense cataract or vitreous opacities, high
myopia, and poor patient cooperation are factors
that may compromise the accuracy of the
biometry results  inducing errors in both AL
and ACD measurement (Chong, 2016)
ACD reported to increase by up to 1.4 mm due to
the posterior shift of ELP induced by cataract
surgery
Combined phacovitrectomy
associated with more frequent postoperative
refractive deviations
Refractive deviations in patients with a preoperative
visual acuity worse than 5/200, underscoring that
patients’ cooperation is a major contributor to precise
biometry results (Jeoung, 2007)
 DISCUSSION

Postoperative deviation greater than 0.5 D was

also associated with a shallower anterior
chamber (Devgau, 2004)

• Inherent weakness of the SRK/T  inaccurate

results when measuring eyes with shorter ACD
• Shallow anterior chamber due to a thicker
crystalline lens  may result in variable ELP
(Olsen, 2006)
STRENGTH AND LIMITATION

STRENGTH

05
LIMITATION 04
03 This is the first research comparing PE between
combined phacovitrectomy and sequential
cataract surgery
02 Considering a history of preexisting macular pathology
01  favorable functional outcome
Included consecutive patients  minimizes selection bias

Explains 2 different types of IOLs during cataract surgery, thus contributing

to a possible bias
The cases were not matched for differences or similarities or other
potential factors that may influence the outcome
Conclusion
CONCLUSION

01 Significant postoperative PE is more commonly seen in combined

procedures compared to sequential surgery

Refractive predictive error is more significant in eyes with

02 smaller ACD, worse baseline VA, and CMT greater than 300 μ.