Treatment of Macular Hole and Cataract as a 1-Step Procedure
Treatment of Macular Hole and Cataract as a 1-Step Procedure
Background/aims 23-gauge pars plana vitrectomy (ppv) is a new method for vitreo-retinal surgery. It may reduce operation time, the risk of complications, and patient discomfort, especially in combination with simultaneous bimanual microincisional cataract surgery (b-MICS).
Methods Seventy-five consecutive patients who underwent combined cataract surgery and ppv at our center between 1 January 2008 and 31 December 2010 were included. The first 36 patients were treated with 20-gauge ppv, the following 39 patients with 23-gauge ppv. Study end points 8 weeks after surgery were duration of the procedure, improvement of visual acuity, and occurrence of complications.
Results Duration of surgery was reduced in 23- vs 20-gauge ppv (54.0±11.6 vs 61.0±19.0 min, P=0.08). Visual acuity improved significantly in both the groups (20-gauge: logMAR 0.750±0.304 before and 0.369±0.273 after surgery; 23-gauge: logMAR 0.663±0.340 before and 0.339±0.273 after surgery). There were no appreciable group differences in baseline or post-treatment visual acuity.
Conclusions 23-gauge ppv in combination with b-MICS is a suitable, safe, and effective method for the treatment of combined cataract and vitreo-retinal diseases. The procedure is somewhat shorter and patient discomfort during and after surgery is improved. In terms of efficacy and safety, 23-gauge ppv is equivalent with conventional 20-gauge ppv.
Pars plana vitrectomy (ppv) was introduced in the 1970s as a method for the removal of an opaque vitreous, and the indication for surgery has substantially broadened since as a consequence of a multitude of technical advancements. Contemporary indications for ppv include retinal detachment, epiretinal membranes, macular holes, diabetic retinopathy, vitreous hemorrhages, proliferative vitreoretinopathy, retinal vein occlusion, and rare vitreous and retinal pathologies. All these pathologies coexist with cataract formation. Consequently, combined vitreo-retinal and cataract surgery has been established during the 1980s and 1990s and is under discussion up to date.
One of the aforementioned technical developments is the employment of small-caliber instruments first described by Fujii et al in 2002. For the first approximately three decades, ppv was usually performed with 20-gauge instruments that were inserted into the vitreous via a sclerotomy through the pars plana; the resulting scleral cut typically requires surgical sealing with sutures. By contrast, small-gauge instruments can be inserted in the vitreous through a so-called 'port' and typically do not require suturing. Another advantage of the small-gauge vitrectomy is the reduced surgical trauma, but the approach has also caliber-related disadvantages such as a longer duration of vitreous extraction, less stability of the instrument itself, and poorer illumination of the retina.
It has been proposed that small-gauge vitrectomy reduces patient discomfort and the risk of inflammatory or infectious complications; consequently, the acceptance and clinical application has increased considerably over the past decade. However, the evidence for such benefits is inconsistent, and the practical realization of potential advantages is subject to a number of important confounding factors, most prominently the surgical skill and experience of the surgeon. It is proposed that certain interventions—especially more extensive procedures—still require standard 20-gauge instruments, and moreover,20-gauge ppv is doubtlessly still the 'gold standard' against which technical and surgical innovations have to be measured in terms of efficacy and safety.
Ppv in combination with extracapsular cataract extraction has traditionally been performed as a two-step procedure, but the single-session surgery appears to be equally effective. However, a reduced inflammatory reaction is considered to be an advantage of the two-step approach, and therefore, small-gauge ppv is of particular interest for the one-step combination of vitreo-retinal and cataract surgery.
A number of authors performed combined operations with increasing frequency, and the introduction of microincisional cataract surgery (MICS) was paralleled by technical improvements of the 23-gauge instruments. Therefore, the clinical application of 23-gauge ppv was considered a promising alternative to the conventional 20-gauge ppv for combined cataract and vitreo-retinal surgery; this approach has not been evaluated systematically yet.
The present study investigates the feasibility, safety, and efficacy of 23-gauge ppv in patients with macular hole and cataract in comparison to the conventional 20-gauge ppv. Study end points were:
Abstract and Introduction
Abstract
Background/aims 23-gauge pars plana vitrectomy (ppv) is a new method for vitreo-retinal surgery. It may reduce operation time, the risk of complications, and patient discomfort, especially in combination with simultaneous bimanual microincisional cataract surgery (b-MICS).
Methods Seventy-five consecutive patients who underwent combined cataract surgery and ppv at our center between 1 January 2008 and 31 December 2010 were included. The first 36 patients were treated with 20-gauge ppv, the following 39 patients with 23-gauge ppv. Study end points 8 weeks after surgery were duration of the procedure, improvement of visual acuity, and occurrence of complications.
Results Duration of surgery was reduced in 23- vs 20-gauge ppv (54.0±11.6 vs 61.0±19.0 min, P=0.08). Visual acuity improved significantly in both the groups (20-gauge: logMAR 0.750±0.304 before and 0.369±0.273 after surgery; 23-gauge: logMAR 0.663±0.340 before and 0.339±0.273 after surgery). There were no appreciable group differences in baseline or post-treatment visual acuity.
Conclusions 23-gauge ppv in combination with b-MICS is a suitable, safe, and effective method for the treatment of combined cataract and vitreo-retinal diseases. The procedure is somewhat shorter and patient discomfort during and after surgery is improved. In terms of efficacy and safety, 23-gauge ppv is equivalent with conventional 20-gauge ppv.
Introduction
Pars plana vitrectomy (ppv) was introduced in the 1970s as a method for the removal of an opaque vitreous, and the indication for surgery has substantially broadened since as a consequence of a multitude of technical advancements. Contemporary indications for ppv include retinal detachment, epiretinal membranes, macular holes, diabetic retinopathy, vitreous hemorrhages, proliferative vitreoretinopathy, retinal vein occlusion, and rare vitreous and retinal pathologies. All these pathologies coexist with cataract formation. Consequently, combined vitreo-retinal and cataract surgery has been established during the 1980s and 1990s and is under discussion up to date.
One of the aforementioned technical developments is the employment of small-caliber instruments first described by Fujii et al in 2002. For the first approximately three decades, ppv was usually performed with 20-gauge instruments that were inserted into the vitreous via a sclerotomy through the pars plana; the resulting scleral cut typically requires surgical sealing with sutures. By contrast, small-gauge instruments can be inserted in the vitreous through a so-called 'port' and typically do not require suturing. Another advantage of the small-gauge vitrectomy is the reduced surgical trauma, but the approach has also caliber-related disadvantages such as a longer duration of vitreous extraction, less stability of the instrument itself, and poorer illumination of the retina.
It has been proposed that small-gauge vitrectomy reduces patient discomfort and the risk of inflammatory or infectious complications; consequently, the acceptance and clinical application has increased considerably over the past decade. However, the evidence for such benefits is inconsistent, and the practical realization of potential advantages is subject to a number of important confounding factors, most prominently the surgical skill and experience of the surgeon. It is proposed that certain interventions—especially more extensive procedures—still require standard 20-gauge instruments, and moreover,20-gauge ppv is doubtlessly still the 'gold standard' against which technical and surgical innovations have to be measured in terms of efficacy and safety.
Ppv in combination with extracapsular cataract extraction has traditionally been performed as a two-step procedure, but the single-session surgery appears to be equally effective. However, a reduced inflammatory reaction is considered to be an advantage of the two-step approach, and therefore, small-gauge ppv is of particular interest for the one-step combination of vitreo-retinal and cataract surgery.
A number of authors performed combined operations with increasing frequency, and the introduction of microincisional cataract surgery (MICS) was paralleled by technical improvements of the 23-gauge instruments. Therefore, the clinical application of 23-gauge ppv was considered a promising alternative to the conventional 20-gauge ppv for combined cataract and vitreo-retinal surgery; this approach has not been evaluated systematically yet.
The present study investigates the feasibility, safety, and efficacy of 23-gauge ppv in patients with macular hole and cataract in comparison to the conventional 20-gauge ppv. Study end points were:
the procedure's duration,
the improvement of the visual acuity, and
the incidence of complications after the procedure.
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