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

Department of Ophthalmology, University of Patras Medical School, Patras, Greece

ABSTRACT
JOURNAL
THEORY
 ANATOMY OF
MACULAR HOLE
MACULAR HOLE
MACULAR HOLE
Defect of the foveal retina
involving its full thickness from
the internal limiting membrane ETIOLOGY:
(ILM) to the 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
 COMBINED PHACOVITECTOMY

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

https://youtu.be/1i_X5QCBmOc
 CATARACT SURGERY
FOLLOWING VITRECTOMI
 CATARACT SURGERY FOLLOWING VITRECTOMI

significantly
improves
visual acuity
in 85% of Combined cataract
cases surgery and pars
Complication: plana vitrectomy
posterior
capsule
opacification https://youtu.be/
or refractive ozK_dnU-zyY
errors

Contents Limited by retinal

Title comorbidity and
surgical
complications

(Esteban, 2020)
INTRODUCTION
 INTRODUCTION
IMPORTANT TO:
PPV combined with Investigated the accuracy
phacoemulsification and MH and ERM still of preoperative biometry in
IOL implantation has expected to have
combined phacovitrectomy
become a common, and cataract surgery as a and compared it cataract
safe procedure sequential procedure. surgery following vitrectomy

This combination The combined and

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

Study
Thype Location Sample Sampling

Retrospective Ophthalmica Eye All reported operations Total Sampling

Study Institute in combined
Thessaloniki phacovitrectomy or
Greece cataract surgery
following vitrectomy
2015 and 2017
 CLINICAL DATA
Procedure 109 eyes of 109 patients
• There was no clinically significant
PPV for full-thickness MH repair or
cataract  sequential surgery
removal 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
biomicroscopy
to measure SE and measured using an
and intraocular
keratometric values optical biometry Lenstar
pressure
preoperatively and 1 month 9000 Alegro Biograph
measurement
postoperatively

1 2 3 4 5 6

Biometric calculations Analysis using an

MH or ERM was
of IOL power using absolute biometry PE,
confirmed by OCT
the SRK/T formula. with an 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
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

Postoperative refractive deviation >1 D was Independent t-test
group associated with shallower ACD (p =
observed 10/55 eyes (18%) in group 1 and in analysis
0.011) and increased central macular
3/54 eyes (5.6%) in group 2 (p = 0.073). Showed a statistical
thickness (CMT) (p = 0.04).
significance (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 Not correlated (p > 0.05) with
power, the use of gas tamponade, or ocular postoperative refractive
parameters 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.
 DISCUSSION

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

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

• Cataract surgery in this setting results in

postoperative refractive errors A myopic shift, among both phakic (− 1.60 D)
• Vitrectomized with phacoemulsification and pseudophakic (− 0.59 D) patients
prone to refractive deviations (Treumer , (Migueal, 2018)
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
01 pathology  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
01 Significant postoperative PE is more commonly seen in
combined procedures compared to sequential surgery

Refractive predictive error is more significant in eyes

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