August 2012

 

CATARACT

 

Tracking cataract formation after vitreoretinal surgery


by Vanessa Caceres EyeWorld Contributing Writer
   

The combination of vitrectomy (pictured here) and scleral buckle can lead to a higher risk of cataract formation than other vitreoretinal procedures Source: Louis D. "Skip" Nichamin, M.D.

Some procedures seem to increase the risk

If you're treating younger patients with a clear lens, you may want to avoid performing both vitrectomy and scleral buckle if possible. The combination of these two procedures led to a higher risk of cataract formation compared with other vitreoretinal procedures, according to a poster presented at the 2012 Association for Research in Vision and Ophthalmology (ARVO) meeting.

The research, led by Ron A. Adelman, M.D., associate professor of ophthalmology and visual science, and director, Yale Retina Service, New Haven, Conn., and Hao Feng, Yale School of Medicine, aimed to evaluate the incidence and prevalence of cataract in patients who had undergone scleral buckle; 20-, 23-, or 25-gauge vitrectomy; or pneumatic retinopexy. Some patients had a combination of two of these procedures.

The retrospective case-control study involved patients who had undergone vitreoretinal procedures at Yale Eye Center between 2002 and 2009. The patients had to have at least 6 months of follow-up and no previous intraocular surgeries. A total of 193 eyes were ultimately included in the study; those patients had been treated for retinal detachment, vitreous hemorrhage, retinitis, macular hole, epiretinal membrane, central retinal vein occlusion, and other conditions. Fifty-three of the eyes underwent 20-gauge vitrectomy, 47 had 23- or 25-gauge vitrectomy, 32 had a scleral buckle procedure, 13 had pneumatic retinopexy, and 35 had combined vitrectomy with a scleral buckle procedure.

The investigators found that 70% of patients who had the combined vitrectomy and scleral buckle procedure had undergone cataract extraction within 24 months post-op. In the 23- and 25-gauge vitrectomy group, 42% had had cataract extraction within 24 months. Forty-one percent of the 20-gauge vitrectomy patients had undergone cataract extraction within 24 months. Only 6% of the scleral buckle and 7% of the pneumatic retinopexy patients had had cataract extraction within that same time frame. "There was a significant amount of cataract formation after vitroretinal surgery but not an equal amount among the different types of surgery," Dr. Adelman said. "Combined vitrectomy and scleral buckle have a higher incidence, while scleral buckle alone had a lower incidence."

The most dramatic increase in the need for cataract extraction occurred within the 6- to 12-month post-op period, Dr. Adelman said.

"The average amount of lens grading changes from pre-operative to the final examination were 1.7 for 20-gauge vitrectomy, 1.2 for 23- and 25-gauge vitrectomy, 0.5 for scleral buckle, 0.5 for pneumatic retinopexy, and 2.1 for combined vitrectomy and scleral buckle," the investigators reported in their poster.

Dr. Adelman said even though some previous research has shown similar results, he thought this would be an interesting area to research with recent changes in vitreoretinal technology and technique. Dr. Adelman is not new to researching the incidence of cataract formation; in a study published in 2003 in Ophthalmology, he and fellow investigators found a 24% rate of cataract extraction after initial trabeculectomy in glaucoma patients aged 12 to 54 years old. The mean time from surgery to cataract formation was 26 months.

Research implications

Allen C. Ho, M.D., Glenside, Pa., found the study interesting but would like to see a similar study that is not retrospective. He also thinks it would be helpful to know in the future about gas placement in the eye in the patients who are studied, as that can affect cataract formation. The study proves the risk for cataract progression is small in patients who undergo scleral buckle or pneumatic retinopexy repair for retinal detachments, said James M. Maisel, M.D., clinical assistant professor of ophthalmology, Hofstra School of Medicine, Hempstead, N.Y. Dr. Maisel also believes that the high incidence of cataract associated with vitrectomy will prompt further efforts to reduce performance of that procedure. "My personal approach is to minimize operative time, microscope light exposure, fluid exchange, and to use the fastest resorbing gas that works for that patient," Dr. Maisel said. This approach has led his routine macular pucker and hole surgeries to be less than 30 minutes. Additionally, Dr. Maisel prefers total air fill after indocyanine green staining and internal limiting membrane peel after several days of facedown positioning. "Xenon gas that disappears overnight may be too short acting, while air works well and is not nearly as cataractogenic as SF6 [sulfur hexafluoride] or C3F8 [octafluoropropane]," he said. Cases that are more complicated and that require longer gas fill can sometimes avoid cataract formation if the patient sleeps prone and intermittently rinses the lens with facedown positioning, Dr. Maisel said.

Editors' note: The doctors mentioned have no financial interests related to this article.

Contact information

Adelman: 203-464-4295, mehran.afshari@yale.edu
Ho: 215-233-4300, acho@att.net
Maisel: 516-939-6100, jmaisel@rgony.com

Tracking cataract formation after vitreoretinal surgery Tracking cataract formation after vitreoretinal surgery
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