The Stellaris PC
The 20-gauge Stellaris Posterior Vitrectomy Pack Source (all): Bausch + Lomb
There's so much more to combining surgery than a dropped nucleus
Think of modern cataract surgery and you might automatically think of some other terms, like refractive lens exchange or simply
refractive surgery. In Japan, doctors are thinking of something seemingly very different: vitrectomy. That might strike U.S. surgeons as odd given that sometimes vitrectomy is what's needed when cataract surgery goes wrong, resulting in posteriorly dislocated lens material that needs a surgical resolution. But in Japan, for a multitude of reasons, combined cataract and vitrectomy surgery is popular,
providing benefits for both patients and surgical staff alike.
Origins of combined surgery
In Japan, combined cataract and vitrectomy dates back about 20 years, before which combined procedures were not favored, said Shunji Kusaka, M.D., professor of ophthalmology, Sakai Hospital, Kinki
University Faculty of Medicine, Osaka, Japan. "At that time, people were opposed to the idea of doing combined surgery," he said. "But [new] research was showing excellent results." At that time, phacoemulsification was being introduced in a more widespread fashion in Japan. Meanwhile, Japan's vitreoretinal surgeons were being trained as good phacoemulsification surgeons. "On our way to training for vitreoretinal surgery, we have to first perform phaco," said Dr. Kusaka. "After that we can do vitrectomy. For us, performing cataract surgery is an easier procedure compared to vitrectomy. That's why we don't have any hesitation about performing simultaneous cataract and vitrectomy surgery." Fair enough. Japan's ophthalmologists seem well trained to perform both procedures and at the same time. But why do so? In answering this question, Dr. Kusaka cited four important uses (in order of popularity) of the Stellaris PC (Procedural Choice) Vision Enhancement System (Bausch + Lomb, Rochester, N.Y.), which provides the ability to perform both cataract and vitreoretinal surgery on the same device. The majority of procedures performed on that machine would be cataract surgery alone. Surgeons also can perform combined surgery—cataract surgery followed by vitrectomy. Then surgeons might use the device for vitrectomy alone. And finally, in rare cases, surgeons could use it to perform unplanned vitrectomy, such as after a cataract surgery that involved a dropped nucleus. Vitrectomy combined immediately afterward with cataract surgery is more popular than vitrectomy alone because of a visual benefit, Dr. Kusaka said. "If the patient is over 50, and we perform vitreous surgery only, the patient will develop cataract afterward," Dr. Kusaka said. "But if we perform cataract and vitrectomy simultaneously, the patient will not require surgery afterward." Yusuke Oshima, M.D., associate professor of ophthalmology, Osaka University Graduate School of Medicine, Suita, Japan, agreed. "Vitreoretinal disease complicated with dense cataract is one of the challenging situations for vitrectomy because lens opacification often obscures clear fundus visibility during surgery," Dr. Oshima said. "In addition, cataract progression after lens-preserving vitrectomy is often seen in elder patients and has been recognized as one of the major vision-threatening complications after vitrectomy. These problems challenging to vitrectomy can be easily settled by performing combined phaco/vitrectomy." Japan's version of Medicare also is partly responsible for the popularity of the combined procedure. "When you do combined phaco/vitrectomy in Japan, the surgical expense for cataract surgery will be discounted 50% from the original cost," Dr. Oshima said. "That is, combined phaco/vitrectomy costs the full charge for vitrectomy plus only 50% of the charge for cataract surgery. Personally, combined phaco/vitrectomies constitute over 75% of my cases."
Vitreoretinal surgeons who are
familiar with cataract surgery shouldn't find phaco/vitrectomy challenging, Dr. Oshima said. "However, the posterior pathologies may sometimes make the phaco part somewhat difficult to deal with compared to simple cataract cases," Dr. Oshima said. "For example, dense vitreous hemorrhage often obscures the red reflex from the fundus for performing the capsulorhexis. Hypotony in the longstanding retinal detachment cases often induces a deepened anterior chamber [AC] with floppy iris during phaco surgery even with a normal fluidics setting." Small pupil cases, dense cataracts, and shallow anterior chambers also provide challenging situations with combined surgery, just as they would for cataract surgery alone, he said. "There are also some considerations regarding how to sequence the anterior and posterior procedures in the combined surgery," Dr. Oshima said. "However, most of these considerations and arguments depend on surgeons' preferences."
Pearls and preferences
It appears surgeons have their own preferences among machines that can do combined work. "Compared to other machines there are only two available with a high cut rate: Stellaris PC and
Constellation [Vision System, Alcon, Fort Worth, Texas]," Dr. Kusaka said. "The Stellaris PC machine is much more compact. It should be a little less expensive than the Constellation, too. Further, preparing the procedure takes less time compared to the Constellation." The space-saving aspect of Stellaris should be of great benefit to Japanese ORs.
"For example, my OR is small," Dr. Kusaka said. "So we cannot have too many machines around the patient. Having one compact machine is very convenient both for docs and nurses." In the case that vitrectomy has to be performed after cataract surgery as a measure to remedy a subluxated nucleus, combining two machines into one could more easily accommodate the situation and destress it, leading to fewer mistakes, he said. Dr. Oshima uses both machines himself. "Both machines have wonderful venturi pump phaco and vitrectomy systems for performing combined phaco/vitrectomy," Dr. Oshima said. "Currently, the Stellaris PC has only a single line for both anterior irrigation and posterior infusion. So when you are using the Stellaris PC, you first complete phaco surgery and then remove the irrigation line from the I/A handpiece to connect to an infusion tube for starting vitrectomy. If you want to go back to irrigate the anterior chamber, you have to take care to remove the posterior infusion line [and change to use it] for anterior segment irrigation."
for select patients
Certain patients can expect to benefit greatly from combined vitrectomy and cataract surgery. "For macula surgeries such as vitrectomies for macular holes and epiretinal membrane proliferation, combined phaco/vitrectomy consisting of a phaco surgery and IOL implantation through a 2.2 mm clear corneal incision and a 25-gauge transconjunctival sutureless vitrectomy is my preferred choice," Dr. Oshima said. This "advanced surgical procedure will provide early and permanent visual recovery with less patient discomfort because the sutureless procedures in both cataract and vitreous surgery minimize ocular surface abnormalities after surgery, and small self-sealing wounds may induce very limited astigmatism." Visual recovery after a combined procedure can be expected beginning at 1 month post-op for these pathologies, he said. "Especially for macular hole and epiretinal membrane proliferation, combined phaco/vitrectomy may not only facilitate early visual recovery in those complicated with pre-existing cataracts but also maintain longitudinal visual stability because of eliminating the concern about the vitrectomy-induced cataract progression," Dr. Oshima said.
Further, posterior capsular opacification poses no threat.
"I usually perform posterior capsulotomy after IOL insertion into the capsular bag so I have no concerns about posterior capsular opacification, which is sometimes seen in phaco-cataract surgery," Dr. Oshima said. "The combined procedure is also very beneficial for retinal detachment surgery because vitreous shaving can be performed reaching to the far periphery much more extensively and thoroughly without the concern of bumping the lens. Similarly, for diabetic cases, pan retinal photocoagulation [PRP] can be engaged to the far peripheral portion." Modern phacoemulsification and vitrectomy also have minimized inflammation post-op, which can be further managed with topical or subconjunctival steroids in challenging cases, Dr. Oshima said.
Dr. Oshima said some minor complications do exist with combining the procedure.
"The most often seen complication in the combined phaco/ vitrectomy may be the posterior synechiae," Dr. Oshima said. "According to previous literature, the rate of posterior synechiae has been estimated to range from 10-30%. This complication will be highly seen in the cases with inflammatory retinal pathologies such as advanced proliferative diabetic retinopathy and in cases with the use of a gas tamponade. When these two risk factors combine, the incidence rate will be much higher, reaching to over 50% reportedly." In eyes in which a gas tamponade has been performed, the IOL could also slide out of the capsular bag, he said. "Overall there are no serious drawbacks with the combined
procedure," he said.
Editors' note: Dr. Oshima has financial interests with Alcon. Dr. Kusaka has
financial interests with Bausch + Lomb.