Abstract
A retrospective review of 98 cases of complicated cataract surgery and/or delayed intraocular lens (IOL) dislocation examined the relationship between vitrectomy and cataract surgery complications. Nine (9.2%) of the 98 patients had a history of vitrectomy, before or after cataract surgery, and each had complicated cataract surgery. Six patients who underwent vitrectomy before cataract surgery experienced intraoperative complications. Three patients in whom vitrectomy was performed after uneventful cataract surgery subsequently had delayed IOL dislocation.
Introduction
Among the most serious complications of cataract surgery are posterior capsular rupture, vitreous loss, retained lens fragments, and intraocular lens (IOL) dislocation. Studies have reported the incidence of capsular rupture to be 1.0–1.7% and IOL dislocation to be 0.2–2.0%.1–8 Lens/IOL dislocation may result in cystoid macular edema, rhegmatogenous retinal detachment, prolonged intraocular pressure elevation, phacoanaphylactic glaucoma, vitreous hemorrhage, pupillary synechiae, prolonged corneal edema, corneal decompensation, and endophthalmitis.9–12
Recognized conditions that increase the risk of complicated cataract surgery and IOL dislocation include pseudoexfoliation syndrome, facial/ophthalmic trauma, advanced age, chronic uveitis, high myopia, retinitis pigmentosa, and ectopia lentis.13–16 As the number of patients undergoing vitrectomy surgery continues to grow, an increasing number of patients who require cataract surgery have a history of vitrectomy and an increasing number of patients who require vitrectomy have a history of uncomplicated cataract surgery and IOL replacement. These patients are at increased risk of experiencing either intraoperative or delayed complications as a result of vitrectomy surgery.17–23
We examined all cases of complicated cataract surgery and/or delayed IOL dislocation over a 15-year period to assess the risk of complicated cataract surgery in patients with a previous or subsequent vitrectomy. We hypothesize that vitrectomy surgery alters the zonular strength and/or capsular bag stability, which may increase the risk of (1) complications in subsequent cataract surgery or (2) IOL dislocation in eyes with previous cataract surgery.
Methods
University of Missouri Institutional Review Board approval was obtained for this study. The medical records of all patients undergoing cataract surgery at one institution over a 15-year period were examined. Patients were included in the study if they had complicated cataract surgery, including lens subluxation, dislocation and retained lens fragments and/or IOL dislocation. Information gathered for each patient included the following: patient demographics, indication for vitrectomy surgery, other intraocular procedures associated with vitrectomy surgery, posterior chamber IOL lens type, intraoperative complications (if any) during cataract surgery, the interval between cataract surgery and IOL subluxation/dislocation, the interval between vitrectomy surgery and complicated cataract surgery, preoperative best-corrected visual acuity (BCVA), final BCVA, and management of the subluxed/dislocated IOL.
Patients were excluded if they had recognized risk factors for complicated cataract surgery or delayed IOL dislocation. These factors included pseudoexfoliation syndrome, retinitis pigmentosa, previous facial/ophthalmic trauma, advanced age (over 90 years at the time of surgery), chronic uveitis, high myopia, and ectopia lentis.
A single unmasked examiner reviewed the medical and surgical records of each patient. Patients were excluded if information was incomplete.
Results
A total of 5,831 patients underwent cataract surgery during the study period. There were 98 cases (1.7%) of complicated cataract surgery, including lens subluxation, dislocation, and retained lens fragments, or of IOL dislocation.
Nineteen of these 98 patients had known risk factors for capsular rupture, zonular dehiscence, or lens/IOL dislocation. Patients with known risk included seven patients with pseudoexfoliation (7.1%), five patients (5.1%) with retinitis pigmentosa, three patients (3.1%) with previous significant facial or ophthalmic trauma, two patients (2.1%) with advanced age, one patient (1.0%) with Marfan syndrome, and one patient (1.0%) with chronic uveitis. Seventy (71.4%) of the 98 patients had no known risk factors for complicated cataract surgery.
Nine (9.2%) of the 98 patients had associated vitrectomy surgery. Six of these nine patients had vitrectomy surgery before cataract surgery and then at a later date had subsequent complicated cataract surgery. Three of the nine patients had undergone uncomplicated cataract surgery before vitrectomy surgery at a later date, and in these patients vitrectomy surgery was followed by subsequent IOL dislocation. The nine patients who experienced lens complications associated with vitrectomy surgery are the focus of our study.
The average interval between prior vitrectomy and cataract surgery was 2.5 years (range: 0.2–10 years) in the six patients who had complicated cataract surgery after vitrectomy. Complications included capsular rupture in all six patients, intravitreal cavity lens fragments in five patients, and zonular weakness in two patients. Four of the six patients had adequate capsular support to place a sulcus-based posterior chamber intraocular lens. In two patients an anterior chamber IOL lens was placed because of inadequate capsular support. All six patients required repeat vitrectomy surgery to manage the complications of their cataract surgery.
The average interval between cataract surgery and vitrectomy surgery was 6.1 years (range: 5.5–6.7 years) in the three patients who underwent uneventful cataract surgery and then had vitrectomy surgery and IOL dislocation. The IOL type in all three patients was a 3-piece polymethyl methacrylate (PMMA) IOL. All three patients were managed by repeat vitrectomy surgery, with placement of a sutured posterior chamber IOL in the sulcus.
The average age of the overall group of nine patients with lens complications associated with vitrectomy and cataract surgery was 62.5 years (range: 45–80 years). Seven patients were male and two were female. Eight patients were Caucasian and one was Hispanic. Indications for vitrectomy surgery in the nine patients included proliferative diabetic retinopathy in four patients, retinal detachment in three patients, retinal detachment with a giant retinal tear in one patient, and subretinal choroidal neovascular membrane removal in one patient.
Vitreoretinal procedures performed at the time of vitrectomy included endolaser (scatter or barrier) in five patients, scleral buckle in four patients, membrane peel in three patients, extended gas tamponade in three patients, exo-cryopexy in two patients, silicone oil tamponade in one patient, air tamponade in one patient, and retinotomy in one patient. One patient had no associated vitreoretinal procedures at the time of vitrectomy.
The mean BCVA for the nine patients was 20/135. The final BCVA was 20/120. The mean length of follow up following the last ocular procedure was 39 months (range: 3–102 months).
Discussion
Our study adds to the evidence that vitrectomy surgery is a risk factor for complicated cataract surgery and IOL dislocation. Cataract surgery is the most common ocular surgery performed worldwide. Because of improving vitreoretinal techniques, vitrectomy surgery is becoming increasingly common as its range of indications continues to expand. As a result, an increasing number of patients undergoing cataract surgery have had previous vitrectomy surgery. Additionally, many patients undergoing vitrectomy surgery have had previous cataract surgery. Our study suggests that vitrectomy before or after cataract surgery increases the risk of complications associated with cataract surgery.
Predisposing risk factors for complicated cataract surgery and IOL dislocation in our patients were similar to those previously reported, such as pseudoexfoliation, retinitis pigmentosa, facial or ophthalmic trauma, advanced age, Marfan syndrome, and chronic uveitis.13–16 We found that vitrectomy surgery as a risk factor for lens complications in cataract surgery was as common as that previously reported. In our patients with complicated cataract surgery, 9.2% had associated vitrectomy surgery, as compared with a rate of complicated cataract surgery of 7.1% in association with pseudoexfoliation, 5.1% with retinitis pigmentosa, and 3.1% with facial/orbital trauma.
Other studies have examined outcomes of previously vitrectomized eyes,17–21 with particular attention to the incidence of lens/IOL dislocation. In a study of 25 cases of “in-the-bag” posterior chamber IOL dislocation, contributing factors to IOL dislocation were zonular weakness, zonular dialysis, and contraction of the capsular bag.22 No cases had associated vitrectomy surgery. Another study found “in-the-bag” dislocation occurred more commonly in patients with pseudoexfoliation, retinitis pigmentosa, trauma, and myopia.23 Vitrectomy surgery had previously been performed in 5% of the patients in this study. “Out-of-the-bag” dislocation was seen with secondary implantation of an IOL into the sulcus and with mature cataract.
The mechanisms by which vitrectomy surgery leads to cataract surgery complications are unknown. Certainly, the mechanics of phacoemulsification are altered in eyes with previous vitrectomy, in which the anterior chamber is deeper and the lens is less stable. In eyes without previous vitrectomy surgery, the vitreous may serve as a “cushion” to stabilize the lens and decrease anterior and posterior movement during phacoemulsification. Additionally, it may be that the pupils of eyes with previous vitrectomy surgery do not dilate as widely, increasing the risk of capsular tear or rupture.
Zonular stability plays an important role in avoiding complications during cataract surgery as well as preventing IOL dislocation. Although the zonular adherence to the lens is well described, peripheral zonular adhesions are less well understood. Rohen24 has described the zonules anchoring between the ciliary processes at a common point, whereas Farnsworth25 has shown that some of the zonules pass through the ciliary processes to attach more posteriorly on the pars plana, near the ora serrata.
Vitrectomy surgery results in focal disruption of the vitreous base as instruments are passed in and out of the pars plana sclerotomies. Additionally, vitrectomy surgery may result in more diffuse vitreous-base disruption if the vitreous base is shaved over the peripheral retina and pars plana during aggressive vitreous removal. It is likely that some degree of zonule disruption occurs during vitrectomy surgery, if Farnsworth’s model of posterior zonule adherence is correct. Such zonular disruption would contribute to the increased incidence of lens complications associated with vitrectomy surgery observed in our study.
Conclusion
Our study underscores the importance of considering vitrectomy surgery as a risk factor for complications associated with subsequent cataract surgery. Additionally, previously stable IOLs may be at increased risk of dislocation after subsequent vitrectomy surgery. Eye surgeons must acknowledge these risks and provide informed consent when considering cataract surgery in patients with previous vitrectomy or when considering vitrectomy surgery in patients with previous cataract surgery.
Biography
Moss J. Fenberg, MD, (top left), is currently a vitreoretinal specialist in Durango, Colo. He completed an ophthalmology residency at the Department of Ophthalmology, Mason Eye Institute, and a vitreoretinal fellowship at Boston University Medical Center. Kenneth J. Hainsworth, (top right), graduated from Brigham Young University in 2014 and is currently a certified nurse assistant at University of Missouri Health Care. Frank G. Rieger, III, MD, (bottom left), MSMA member since 1995, is chief of the ophthalmology service at the Harry S. Truman Memorial Veterans’ Hospital, Columbia, Mo. Dean P. Hainsworth, MD, (bottom right), MSMA member since 1997, is the George L. and Melna A. Bolm Distinguished Faculty Scholar in Ophthalmology and Professor of Ophthalmology. He is also medical director of the Clinical Research Center at the University of Missouri Institute for Clinical and Translational Science.
Contact: hainsworthd@health.missouri.edu
Footnotes
Disclosure
D. Hainsworth is a consultant for Katalyst Surgical.
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