Comment on: Microincision phacoemulsification combined with sutureless transpupillary passive silicone oil removal

Dear Editor,

We read the article titled “Microincision phacoemulsification combined with sutureless transpupillary passive silicone oil removal” by Thulasidas et al.,[1] published in the Indian Journal of Ophthalmology, with great interest. We congratulate all the authors for their technique and publication, but we would like to raise a few concerns that we noted in the study.

First, the study was noncomparative in nature without any control group. The authors have concluded that combined microincision phacoemulsification with silicone oil removal (SOR) using irrigation probe of bimanual irrigation/aspiration (I/A) through a planned posterior capsulorhexis is a safe, effective, and less invasive technique. However, in the methodology section, the authors did not consider a control group to compare the results with the conventional three-port pars plana approach. Thus, a future prospective comparative study is desirable to substantiate the findings of the current study.

The authors used fluid jet from the irrigation probe of the bimanual I/A to float out the SO through the transpupillary route, but they have not mentioned how they have ensured complete silicone oil removal (SOR). Intraoperative indirect ophthalmoscopy (IO) often may not ensure complete SOR. Silicone bubbles behind the iris may be missed on IO, which can be otherwise easily visualized with an endo light probe in a conventional pars plana approach. Poor mydriasis and hazy media may further accentuate this problem. Moreover, repeated steps of fluid air exchange (FAE) are often needed to ensure complete SOR, especially in cases with emulsified silicone oil.[2] Retained SO bubbles can migrate from the retro-iridial plane into the anterior chamber in the immediate post-operative period, thereby necessitating a second procedure for removal of the residual silicone oil. The retained emulsified silicone oil bubbles can also migrate to the trabecular meshwork, leading to decreased outflow facility, and cause secondary open-angle glaucoma.[3] Another advantage of FAE during SOR using the conventional pars plana approach is that occult retinal breaks can be detected intraoperatively. Retinal breaks may reveal subtle retinal detachment during FAE, thereby allowing to perform endo-drainage and re-tamponade with gas or silicone oil in the same sitting.[2]

The authors have correctly mentioned that “posterior capsulorhexis should be performed cautiously and only by an experienced surgeon, as an unusually large posterior capsulotomy may lead to IOL dislocation into the vitreous cavity postoperatively.” We would like to add here that phacoemulsification in a prior-vitrectomized eye by itself is a difficult procedure, and is often performed by skillful surgeons.[4] There is a possibility of preexisting posterior capsular weakness due to lens touch during the primary vitrectomy procedure. There is a possibility of intraoperative miosis due to the migration of silicone oil bubbles into the AC through compromised zonules during phacoemulsification. In addition, the posterior support to the nucleus during phacoemulsification is often compromised in such eyes. Therefore, in such a scenario, planned posterior capsulorhexis may not be possible. Conventional pars plana three-port SOR technique can be easily performed in such cases.

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