A multicenter database study of 114 911 eyes found a 4- to 6-fold higher rate of PCR, dropped lens fragments, and macular edema in combined phacovitrectomy compared with stand-alone phacoemulsification.
Abstract
Purpose:
To compare the rates of intraoperative complications, cystoid macular edema (CME), and visual outcomes in eyes that underwent combined phacovitrectomy (Phaco-PPV) with those with stand-alone phacoemulsification.
Setting:
A multicenter database study across 8 ophthalmology departments in the United Kingdom.
Design:
Retrospective, nonrandomized, multicenter comparative study.
Methods:
We extracted data for patients who underwent Phaco-PPV and stand-alone phacoemulsification from January 2000 through May 2015. The primary study outcomes were the rates of intraoperative complications and CME postoperatively.
Results:
The study included 2222 eyes in the combined Phaco-PPV group and 112 689 in the stand-alone phacoemulsification group. The combined Phaco-PPV group had a higher incidence of posterior capsule rupture (2.7% vs 1.7%), dropped lens fragments (0.5% vs 0.2%), suprachoroidal hemorrhage (0.4% vs 0.1%), and CME (3.6 vs 1.1%) (P < .001). The mean preoperative visual acuity (VA) was lower in the combined Phaco-PPV group, with a mean VA of 0.98 vs 0.68 logMAR (Snellen ∼20/200 vs 20/100) in the stand-alone phacoemulsification group (P < .001). VA at 24 weeks was lower in the combined Phaco-PPV group (mean VA 0.67 vs 0.22 logMAR (Snellen ∼20/100 vs 20/32), P < .001).
Conclusions:
Combined Phaco-PPV had higher rates of intraoperative complications and CME, along with a lower postoperative VA, when compared with stand-alone phacoemulsification surgery.
Pars plana vitrectomy (PPV) is used to treat several vitreoretinal conditions, including retinal detachment, epiretinal membranes, macular hole, and advanced diabetic retinopathy.1–3 After PPV, the risk of cataract progression increases, with rates ranging between 60% and 100% after approximately 2 years of follow-up.2,4
The outcomes and cost-effectiveness of combined phacovitrectomy (Phaco-PPV) vs sequential postvitrectomy phacoemulsification surgery have been evaluated in previous studies.5,6 Results demonstrated that Phaco-PPV has a lower cost to the healthcare system than sequential surgery, albeit with a longer operating room time.5,6 Although there is mixed evidence on the rate of complications of cataract surgery when combined with PPV, a recent large-scale study by Elhusseiny et al. showed a higher rate of posterior capsule rupture (PCR) in the combined Phaco-PPV group (2.5%) as compared with post-PPV cataract surgery (0.8%).7 To date, there have been no studies analyzing the perioperative characteristics and intraoperative risks of cataract surgery in the setting of a combined Phaco-PPV as compared with stand-alone routine cataract surgery. While we expect there will be differences in the visual outcome given the coexisting retinal pathology in the combined Phaco-PPV group, the technical challenges of the cataract procedure part deserve evaluation. This information would be necessary for the cataract surgeon taking part in combined Phaco-PPV for surgical benchmarking and patient counseling.
This study aimed to evaluate the rate of intraoperative complications, postoperative cystoid macular edema (CME), and the visual outcomes of combined Phaco-PPV as compared with stand-alone cataract surgery in a large cohort of patients from 8 different UK ophthalmology centers.
METHODS
Data Categorization and Selection Criteria
This was a retrospective review of the medical records of all patients aged 18 years or older who underwent cataract surgery from January 2000 through May 2015 at 8 UK ophthalmology departments, including patients who underwent combined Phaco-PPV and patients who had stand-alone phacoemulsification. We automatically extracted data from the same electronic medical record system (Medisoft Ophthalmology, Medisoft, Ltd.) and pooled it into a centralized database for analysis. The surgeries were performed by a wide range of anonymized cataract surgeons using modern phacoemulsification technologies. All patients were prescribed a topical antibiotic and steroid drops postoperatively with gradual tapering of topical steroids over 4 weeks. All patients were routinely evaluated postoperatively with at least 1 visit at the 4- to 6-week postoperative follow-up interval. We excluded patients with incomplete data and patients with combined surgery other than PPV. To avoid the correlation that can happen from including both eyes of the same patients, we only included the first operated eye of patients who underwent bilateral sequential surgery (Figure 1).
Figure 1.
Flowchart illustrating the filtering process used for data categorization into combined Phaco-PPV and stand-alone phacoemulsification groups. CV = complex vitrectomy; PPV = pars plana vitrectomy; RRD = rhegmatogenous retinal detachment; VO = vitreous opacities; VRI = vitreoretinal interface disorders.
The extracted data included demographics, such as age and sex, side of surgery, indication for PPV, diabetic status, preoperative axial length (AL), cataract grading (advanced brown/white cataract or not), and visual acuity (VA). Fields extracted from the operative record for cataract surgery included pupil size, surgeon grade, type of surgery performed, including combined surgery, details of intraoperative complications, and all subsequent surgery. Recording intraoperative complications in the electronic medical record was a compulsory field before the surgeon could save the operation record. If a complication occurred, the surgeon had to select from a prespecified list of well-recognized cataract surgery complications or select “other” and record the complication using free text. If no complication occurred, the surgeon then chose “none.” The study complied and adhered to the tenets of the Declaration of Helsinki. As the extracted patient information was deidentified at the time of extraction, the study was not classified as human subject research, waiving the need for institutional review board approval.
Study Outcomes
The primary outcome of this study was the incidence of cataract complications in the combined Phaco-PPV group vs stand-alone phacoemulsification. We defined postoperative CME as macular edema developing within 3 months after phacoemulsification. Because retinal diseases affect VA differently from cataract alone, we considered VA a secondary outcome of the study. We designated VA as the best value of uncorrected or corrected distance VA available at each visit. We defined preoperative VA as the recorded VA at the closest visit to the date of surgery, no more than 3 months earlier. We determined the visual gain as a postoperative visual improvement of ≥0.3 logMAR units (∼3 Snellen lines).
Statistical Analysis
We analyzed the data using IBM SPSS Statistics for Windows (v. 27.0, IBM Corp.). We used the chi-square test to analyze differences in proportions as indicated, with a P value threshold for statistical significance of 0.05. We expressed quantitative data as median, mean ± SD, and range. We compared the preoperative characteristics and postoperative outcomes of both groups using a t test. A P value less than 0.05 was considered statistically significant. We fitted several logistic regression analysis models to identify the predictive factors of the development of PCR, zonular dialysis, CME, intraoperative intraocular lens (IOL)-related complications, and rate of IOL exchange surgery.
RESULTS
Preoperative Characteristics
This study included a total of 114 911 eyes: 2222 eyes in the combined Phaco-PPV group and 112 689 eyes in the stand-alone phacoemulsification group. The mean age of patients at the time of cataract surgery in the combined Phaco-PPV group was 70.5 ± 8.2 years compared with a mean age of 75.7 ± 9.3 years in the stand-alone phacoemulsification group (P < .001). There were 1272 female patients (57.3%) in the combined Phaco-PPV group as compared with 6627 (59.2%) in the stand-alone group (P = .06). The mean preoperative AL was 23.5 ± 1.4 mm and 23.4 ± 1.3 mm, respectively (P < .001). Advanced cataract was significantly less in the combined Phaco-PPV group compared with the stand-alone group (0.7 vs 4.1%) (P < .001). A total of 52.8% of surgeries were performed by a consultant (attending level) in the combined Phaco-PPV group compared with 59.4% in the stand-alone group (P < .001). Table 1 summarizes the baseline preoperative characteristics for both groups. For the purpose of analysis, we further subdivided the combined Phaco-PPV group into 4 groups based on the indication for surgery: complex vitrectomy (CV) (diabetic delamination, proliferative vitreoretinopathy), rhegmatogenous retinal detachment (RRD), vitreous opacity (VO), and vitreoretinal interface (VRI) disorder. The characteristics of each subgroup are summarized in Table 2.
Table 1.
Preoperative characteristics of combined phacovitrectomy vs stand-alone cataract surgery
| Parameter | Combined phacovitrectomy | Stand-alone phacoemulsification | P value |
| Eyes, n | 2222 | 112 689 | |
| Age at surgery (y), mean (SD) | 70.5 (8.2) | 75.7 (9.3) | <.001* |
| AL, mean (SD) | 23.5 (1.4) | 23.4 (1.3) | <.001* |
| Female sex, n (%) | 1272 (57.3) | 66 627 (59.2) | .06 |
| Left eye, n (%) | 1092 (49.1) | 51 893 (46) | .004* |
| Diabetic, any type, n (%) | 293 (13.2) | 19 034 (16.8) | <.001* |
| Overall co-pathologies, n (%) | |||
| None | 1183 (53.24) | 76 417 (67.81) | <.001* |
| Single | 962 (43.29) | 26 969 (23.93) | <.001* |
| Multiple | 77 (3.47) | 9303 (8.26) | <.001* |
| AMD, n (%) | 82 (3.7) | 10 368 (9.2) | <.001* |
| Previous trabeculectomy, n (%) | 6 (0.3) | 466 (0.4) | .29 |
| Pseudoexfoliation, n (%) | 6 (0.3) | 1383 (1.2) | <.001* |
| Advanced cataract, n (%) | 15 (0.7) | 4595 (4.1) | <.001* |
| Corneal pathology, n (%) | 13 (0.6) | 3257 (2.9) | <.001* |
| Diabetic retinopathy, n (%) | 232 (10.4) | 5154 (4.6) | <.001* |
| Preop PG, n (%) | 71 (3.2) | 6677 (5.9) | <.001* |
| Glaucoma, n (%) | 49 (2.2) | 8766 (7.8) | <.001* |
| Uveitis, n (%) | 33 (1.5) | 1211 (1.1) | .06 |
| Vein occlusion, n (%) | 82 (3.7) | 1072 (1) | <.001* |
| Preop IVIs more than 10, n (%) | 4 (0.2) | 135 (0.1) | .419 |
| Poor pupillary dilation, n (%) | 62 (2.8) | 4406 (3.9) | .007* |
| Consultant surgeon, n (%) | 1174 (52.8) | 66 891 (59.4) | <.001* |
AL = axial length; AMD = age-related macular degeneration; IVI = intravitreal injection; PG = prostaglandin analogs
Statistically significant
Table 2.
Subgroup division and preoperative characteristics of combined phacovitrectomy eyes by vitrectomy indications
| Parameter | CV | RRD | VO | VRI |
| Eyes, n | 146 | 276 | 220 | 1580 |
| Age at surgery (y), mean (SD) | 65.19 (9) | 68.5 (9.7) | 71.7 (9.5) | 71.1 (7.4) |
| AL, mean (SD) | 23.3 (1.2) | 24.3 (1.9) | 23.2 (1.3) | 23.5 (1.3) |
| Female sex, n (%) | 67 (45.9) | 123 (44.6) | 134 (60.9) | 948 (60.1) |
| Left eye, n (%) | 83 (56.8) | 138 (50) | 115 (52.3) | 756 (47.8) |
| Diabetic, any type, n (%) | 61 (78.2) | 16 (17.6) | 50 (39.4) | 166 (19.8) |
| Overall copathologies/risk factors, n (%) | ||||
| None | 47 | 203 | 113 | 820 |
| Single | 87 | 64 | 86 | 725 |
| Multiple | 12 | 9 | 21 | 35 |
| AMD, n (%) | 0 | 12 (4.3) | 16 (7.3) | 54 (3.4) |
| Previous trabeculectomy, n (%) | 1 (0.7) | 3 (1.1) | 1 (0.5) | 1 (0.1) |
| Pseudoexfoliation, n (%) | 0 | 1 (0.4) | 3 (1.4) | 2 (0.1) |
| Advanced cataract, n (%) | 3 (2.1) | 5 (1.8) | 7 (3.2) | 0 |
| Corneal pathology, n (%) | 0 | 3 (1.1) | 0 | 10 (0.6) |
| Diabetic retinopathy, n (%) | 81 (55.5) | 12 (4.3) | 49 (22.3) | 90 (5.7) |
| Preop prostaglandins, n (%) | 5 (3.4) | 6 (2.2) | 8 (3.6) | 52 (3.3) |
| Glaucoma, n (%) | 2 (1.4) | 6 (2.2) | 12 (5.5) | 29 (1.8) |
| Uveitis, n (%) | 2 (1.4) | 8 (2.9) | 5 (2.3) | 18 (1.1) |
| Vein occlusion, n (%) | 12 (8.2) | 13 (4.7) | 9 (4.1) | 48 (3) |
| Preop IVIs more than 10, n (%) | 0 | 1 (0.4) | 2 (0.9) | 1 (0.1) |
| Poor pupillary dilation, n (%) | 7 (4.8) | 11 (4) | 24 (10.9) | 20 (1.3) |
| Consultant surgeon, n (%) | 106 (72.6) | 154 (55.8) | 100 (45.5) | 814 (51.5) |
AMD = age-related macular degeneration; CV = complex vitrectomy; IVI = intravitreal injection; RRD = rhegmatogenous retinal detachment; VO = vitreous opacity; VRI = vitreoretinal interface disorder
Intraoperative Complications
Table 3 summarizes the rates of different intraoperative complications in both groups. The rate of PCR was significantly higher in the combined Phaco-PPV group (61 eyes, 2.7%) as compared with the stand-alone group (1184 eyes, 1.7%) (P < .001); however, we only found it to be significant in the RRD and VO subgroups on regression analysis (P < .001). As demonstrated in Table 4, our data also showed a significant association with increased age (odds ratio [OR], 1.01), pseudoexfoliation (OR, 2.08), advanced grade of cataract (OR, 2.74), prior intravitreal injections (OR, 3.26), and zonular dialysis (OR, 5.59). There was a significantly lower risk of PCR with a consultant surgeon (OR, 0.56).
Table 3.
Complication rates of combined phacovitrectomy vs stand-alone cataract surgery
| Parameter | Combined phacovitrectomy | Stand-alone phacoemulsification | P value |
| Eyes with complications, n (%) | 206 (9.2) | 4423 (3.9) | <.001* |
| Hyphema, n (%) | 0 | 43 (0.0004) | .35 |
| Endothelial damage, n (%) | 0 | 177 (0.2) | .06 |
| Iris prolapse/trauma, n (%) | 11 (0.49) | 533 (0.47) | .88 |
| PCR, n (%) | 61 (2.7) | 1184 (1.7) | <.001* |
| Zonular dialysis, n (%) | 22 (1) | 753 (0.7) | .066 |
| Intraop IOL-related problems, n (%) | 3 (0.1) | 103 (0.1) | .5 |
| Cataract wound burn, n (%) | 0 | 77 (0.1) | .218 |
| Dropped lens fragments, n (%) | 12 (0.5) | 229 (0.2) | <.001* |
| Corneal edema, n (%) | 1 (0.0004) | 132 (0.1) | .32 |
| Choroidal/suprachoroidal hemorrhage, n (%) | 8 (0.4) | 58 (0.1) | <.001* |
| IOL exchange/reposition surgery, n (%) | 2 (0.1) | 40 (0.0003) | .18 |
| CME, n (%) | 81 (3.6) | 1282 (1.1) | <.001* |
CME = cystoid macular edema; PCR = posterior capsule rupture
Statistically significant
Table 4.
Odds ratio and complication rates for complex vitrectomy, rhegmatogenous retinal detachment, vitreous opacity, and vitreoretinal interface disorder combined phacovitrectomy subgroups
| Parameter | CV | RRD | VO | VRI |
| Posterior capsule rupturea | ||||
| P value | .448 | <.001* | <.001* | .07 |
| Adjusted OR (95% CI) | 1.5 (0.49-4.9) | 3 (1.6-5.6) | 3.8 (2.2-6.6) | 1.3 (0.97-1.98) |
| Dropped lens fragmentsb | ||||
| P value | .99 | .003* | .002* | .96 |
| Adjusted OR (95% CI) | 0 | 5.7 (1.8-17.9) | 5.2 (1.8-15.1) | 1.02 (.3-3.3) |
| Suprachoroidal hemorrhagec | ||||
| P value | .99 | <.001* | .99 | <.001* |
| Adjusted OR (95% CI) | 0 | 45 (15.6-134.2) | 0 | 7.89 (2.7-22.3) |
| Cystoid macular edemad | ||||
| P value | .55 | .8 | .46 | <.001* |
| Adjusted OR (95% CI) | 0.6 (0.16-2.6) | 1.1 (0.4-3) | 0.59 (0.14-2.39) | 4 (3.1-5.1) |
| Zonular dialysise | ||||
| P value | <.001* | .9 | .29 | .7 |
| Adjusted OR (95% CI) | 7.2 (2.9-17.8) | 0 | 1.8 (0.5-5.9) | 1.6 (0.9-2.7) |
| Postop IOL exchangef | ||||
| P value | .054 | .9 | .9 | .6 |
| Adjusted OR (95% CI) | 7.8 (0.9-64) | 0 | 0 | 1.6 (0.2-11.8) |
| Intraop IOL-related problemsg | ||||
| P value | .9 | .002* | .9 | .7 |
| Adjusted OR (95% CI) | 0 | 9.5 (2.3-39) | 0 | 0.7 (0.1-5.2) |
| Iris prolapse/traumah | ||||
| P value | .9 | .9 | .9 | .9 |
| Adjusted OR (95% CI) | 0 | 0 | 0 | 0 |
CV = complex vitrectomy; IVI = intravitreal injection; OR = odds ratio; RRD = rhegmatogenous retinal detachment; VO = vitreous opacity; VRI = vitreoretinal interface disorder
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, axial length, surgeon grade, corneal pathology, poor dilation, pseudoexfoliation, zonular dialysis, and preoperative more than 10 IVI
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, axial length, surgeon grade, corneal pathology, posterior capsular rupture, poor dilation, pseudoexfoliation, zonular dialysis, and preoperative more than 10 IVI
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, posterior capsular rupture, dropped lens fragments, uveitis, diabetic retinopathy, glaucoma, IOL problems, axial length, and surgeon grade
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, posterior capsular rupture, preoperative more than 10 IVI, preoperative prostaglandin use, dropped lens fragments, uveitis, diabetic retinopathy, and IOL problems
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, axial length, surgeon grade, poor dilation, pseudoexfoliation, previous trabeculectomy, and preoperative more than 10 IVI
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, poor dilation, zonular dialysis, pseudoexfoliation, previous trabeculectomy, preoperative more than 10 IVI, IOL problems, axial length, and surgeon grade
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, poor dilation, zonular dialysis, pseudoexfoliation, previous trabeculectomy, preoperative more than 10 IVI, axial length, and surgeon grade
Adjusted for combined vitrectomy subgroups, age, sex, advanced cataract, poor dilation, zonular dialysis, pseudoexfoliation, previous trabeculectomy, axial length, and surgeon grade
Statistically significant
There was no significant difference in the rates of zonular dialysis between the 2 groups (P = .66). However, on regression analysis, there was a higher risk with CV (OR, 7.24), increasing age (OR, 1.01), advanced cataract (OR, 2.96), pseudoexfoliation (OR, 6.03), and poor dilation (OR, 1.49). We also found surgeries performed by consultant surgeons (OR, 0.67) and eyes with longer preoperative AL (OR, 0.9) were associated with a lower risk of zonular dialysis (Table 4).
We found a higher risk of dropped lens fragments in the combined Phaco-PPV group (229, 0.2%, vs 12, 0.5%, P < .001). Regression analysis showed higher odds in the RRD and VO subgroups (P = .003 and .002, respectively). We also found significantly higher odds of dropped lens fragments with increasing age (OR, 1.02), advanced cataract (OR, 3.33), PCR (OR, 98.85), and zonular dialysis (OR, 2.96) while this risk was less for consultant surgeons (OR, 0.7). Combined Phaco-PPV surgery was associated with higher rates of suprachoroidal hemorrhage (8 eyes, 0.4%) compared with the stand-alone group (58 eyes, 0.1%) (P < .001). We found this significant only for cases with RRD and VRI on regression analysis. We also found increased odds with age (OR, 1.05), PCR (OR, 10.67), and glaucoma (OR, 3.74). We did not find differences between the 2 groups regarding iris trauma (P = .88). There was an increased rate of intraoperative IOL-related complications, including lens malposition or exchange in eyes with the RRD group (OR, 9.52), as compared with stand-alone cataract surgery.
Postoperative CME and IOL Exchange
The rate of CME was significantly higher in the combined Phaco-PPV group (81, 3.6% vs 1282 1.2%) (P < .0001). On logistic regression analysis, this was found to be only valid for VRI (OR, 4.04) (Table 4). Other significant predictors of CME include the presence of coexisting diabetic retinopathy (OR, 2.37), uveitis (OR, 2.21), and the occurrence of PCR (OR, 2.03). There was no difference between the 2 groups in terms of the need for a second IOL exchange/reposition surgery. Factors that predicted this outcome included increased preoperative AL (OR, 1.28), zonular dialysis (OR, 26.76), and prior intraoperative IOL complications (OR, 12.29).
Visual Outcomes
Preoperative VA was worse in the combined Phaco-PPV group 0.96 ± 0.66 logMAR (∼20/200 Snellen equivalent) as compared with 0.68 ± 0.53 logMAR (∼20/100) in the stand-alone group (P < .0001). Postoperative VA at 24 weeks was worse in the combined Phaco-PPV group, with a mean VA of 0.67 ± 0.59 logMAR (20/100) and of 0.22 ± 0.34 logMAR (20/32), respectively. The combined Phaco-PPV group had less improvement in vision than the stand-alone surgery group; however, both groups exhibited a mean gain of 0.3 logMAR (∼3 Snellen lines) of VA, with 0.3 ± 0.65 logMAR gain in the combined phaco-PPV group and 0.4 ± 0.5 logMAR in the stand-alone group (P < .001).
DISCUSSION
In this large-scale multicenter study, we aimed to underscore the challenges encountered in cataract surgery when combined with PPV in the same setting, focusing on operative difficulty, surgical safety, and postoperative outcomes. Relative to stand-alone cataract surgery, we observed that combined surgery was linked to significantly elevated rates of PCR (4-fold), dropped lens fragment (6-fold), suprachoroidal hemorrhage (46-fold), and CME (4-fold), although these increased risks varied based on the indication and complexity of the PPV surgery.
We noted a higher likelihood of PCR in eyes undergoing combined Phaco-PPV. Ercalik et al. and Lee et al. demonstrated a lower rate of PCR with combined surgery (1.5%-4.5% vs 4.8%-11.4%) while Port et al. found a higher rate of PCR in the combined group that did not reach statistical significance (5.9% vs 12.8%, P = .312).6,8,9 The latter is consistent with our findings of combined surgery having a higher rate of PCR in eyes operated for RRD and VO. It is possible that the poor red reflex in these surgery subgroups contributed to the increased risk of PCR. The same PPV surgery subgroups had a high rate of dropped lens fragments, likely to have resulted from increased PCR.
There was a 7-fold increase in the risk of zonular dialysis in eyes undergoing combined cataract and CV surgery. The heightened risk of zonular damage is a recognized intraoperative concern with PPV surgery indicative of potential zonular injury during vitreous removal.10,11 This risk is particularly increased in cases where extensive peripheral vitreous dissection is warranted compared with routine non-complex vitrectomy procedures.
We observed a 4-fold increase in the likelihood of CME within the VRI subgroup compared with stand-alone cataract surgery. This increased CME rate may be related to the coexisting retinal pathology. While some increase in macular thickness may occur after uneventful cataract surgery, subtle CME may go unnoticed unless there is a discernible decline in vision, prompting optical coherence tomography (OCT) scanning.12,13 Notably, eyes affected by VRI disorders undergo regular postoperative monitoring with sequential OCT scans, in contrast to other PPV indications such as CV, VO, and RRD. This discrepancy in monitoring practices may contribute to screening bias and, consequently, higher odds of CME in eyes with VRI disorders.
Consistent with previously published literature, we found a higher risk of suprachoroidal hemorrhage in the combined Phaco-PPV surgery group.14,15 The risk was highest for eyes where RRD was the indication for PPV (OR, 45.78). Retinal detachment is a known risk factor of intraoperative suprachoroidal hemorrhage. This may be attributed to fluctuations in intraocular pressure and the need for repeated scleral indentation during surgery. We found a 9-fold higher risk of intraoperative IOL-related complications only with the RRD group. The fluctuations in anterior chamber depth during surgery and the routine use of vitreous tamponade agents during RRD surgery may have affected IOL centration.16,17
Caution is advised when interpreting the VA outcomes in our study because of the presence of vision-involving retinal pathology in the combined group alongside cataract. Eyes that underwent combined Phaco-PPV demonstrated postoperative vision improvement; however, as anticipated, their absolute postoperative vision at 24 weeks was notably inferior to those with stand-alone cataract surgery. Cataract surgeons must emphasize this distinction in visual potential when discussing VA outcomes with patients undergoing combined cataract and vitrectomy surgery as part of managing their expectations.
There are limitations to this study, including its retrospective, noncontrolled design and the unmatched differences in preoperative characteristics between the 2 study groups. Similar to other database studies, some details regarding coexisting pathology or cataract surgery techniques were not fully available. In addition, unlike clinical trials where patients undergo refractive assessments at each clinic visit, retrospective studies do not include this practice. Consequently, our recorded visual acuities more accurately reflect the best habitual refraction recorded rather than strictly adhering to best-corrected measures at every visit. One factor to consider regarding the overall complication rate in the combined Phaco-PPV group is the possible association with the surgical subspecialization of the surgeons when vitreoretinal surgeons perform cataract surgery. The work of Campbell and colleagues highlighted a higher complication rate in patients whose cataract surgery was performed by highly diversified surgeons whose surgical volume consists of >50% non–cataract surgery procedures.18
Our study presents several advantages. It is the first to compare the safety of cataract surgery in a combined Phaco-PPV setting with stand-alone phacoemulsification. The strengths of this study lie in its large-scale and pragmatic design, involving the extraction of structured data from multiple centers. The mandatory capture of intraoperative complications recording ensures high accuracy and completion of records. While acknowledging that a prospective randomized controlled trial is considered the gold standard in evidence, the large scale of the required study makes such an approach unfeasible.
In summary, we found higher rates of complications with combined Phaco-PPV as compared with stand-alone phacoemulsification. This included significantly higher rates of suprachoroidal hemorrhage, PCR, and dropped lens fragments in the vitreous cavity. We also found a 4-fold increase in the risk of postoperative CME with combined Phaco-PPV for VRI and a nearly 10-fold increase in the risk of intraoperative IOL complications. Our findings may hold relevance for anterior segment surgeons performing cataract surgery as part of combined Phaco-PPV surgery, serving as an aid for surgical benchmarking and patient counseling.
WHAT WAS KNOWN
No prior studies compared the safety of cataract surgery in a combined phacovitrectomy setting with stand-alone phacoemulsification.
WHAT THIS PAPER ADDS
In this multicenter database study, we found the rate of posterior capsule rupture, dropped lens fragments, and cystoid macular edema to be higher in combined phacovitrectomy compared with stand-alone phacoemulsification cases by 4-fold, 6-fold, and 4-fold, respectively.
Footnotes
M. Bakr and A.M. Elhusseiny contributed equally to this work.
Disclosures: None of the authors have any financial or proprietary interest in any material or method mentioned.
First author:
Mohammad Bakr, MD
Department of Ophthalmology, UTSW Medical Center, Dallas, Texas
Contributor Information
Mohammad Bakr, Email: mohammadashrafbakr@outlook.com.
Joseph Toma, Email: joseph.hany.toma@gmail.com.
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