To examine the usefulness of 23-gauge pars plana vitrectomy (PPV) in removing retained lens fragments and to determine which cases require 20-gauge ultrasonic fragmentation.
Retrospective comparative case series.
Twenty eyes in 20 consecutive patients who had 23-gauge PPV for retained lens fragments after complicated cataract surgery at Wills Eye Institute were retrospectively reviewed. Retained lens fragments were graded based on percentage of total nuclear size. Every surgical case started with 23-gauge PPV, but 1 sclerotomy was enlarged to facilitate 20-gauge ultrasonic fragmentation if all lens material could not be adequately removed.
Twelve patients (60%) were successfully managed with 23-gauge PPV alone while 8 patients (40%) required 20-gauge ultrasonic fragmentation. The 23-gauge cases had a lower percentage of retained lens fragments (median 10%, range 0% to 75%) compared to the 20-gauge cases (median 90%, range 10% to 100%).
23-Gauge PPV is a feasible approach in the surgical management of select cases of retained lens fragments.
Dislocation of lens fragments into the posterior chamber is a well-known complication of cataract surgery. Pars plana vitrectomy (PPV) offers an effective means of removing retained lens material. For many years, 20-gauge instruments and ultrasonic fragmentation have been used to effectively remove lens fragments from the vitreous cavity. Over the past decade, as small-incision transconjunctival, sutureless PPV has gained increasing popularity, surgeons have employed these techniques for an expanding number of indications. Both 25-gauge and 23-gauge systems have been used to remove retained lens fragments, but certain cases with dense nuclear material still require a 20-gauge sclerotomy to facilitate the use of an ultrasonic fragmatome. The use of a single 20-gauge superior sclerotomy and 2 23-gauge ports, namely 1 superior port for endoillumination and 1 inferotemporal port for infusion, has been previously described for a variety of surgical indications.
Kiss and Vavvas first described the surgical management of 3 patients with retained lens material using 25-gauge PPV. These patients all had retained cortical material, whereas 3 other patients with retained nuclear material required 1 20-gauge port and a fragmatome to remove lens fragments. Recently, Ho and associates also looked at 25-gauge PPV for removing retained lens material. They reported 17 patients with retained lens material who were all successfully managed with 25-gauge PPV alone, including 13 cases with nuclear material. To our knowledge, there are no reports in the literature describing the use of 23-gauge PPV to remove retained lens material. The aim of the current retrospective study is to examine the usefulness of 23-gauge PPV in removing retained lens material and to determine which cases are most amenable to 23-gauge PPV without ultrasonic fragmentation vs 20-gauge PPV with fragmentation.
The medical records of consecutive patients at the Wills Eye Institute Retina Service from March 11, 2008 to June 17, 2008 who underwent PPV for retained lens fragments after complicated cataract surgery were retrospectively reviewed. Patients were referred at different times after cataract surgery and underwent PPV at the discretion of the retinal surgeon. Preoperative, intraoperative, and postoperative patient data were collected from the medical records, including patient demographics, ocular history, best-corrected visual acuity by Snellen eye charts, intraocular pressure, complications, and size and character of retained lens material. In all cases, retained lens fragments were graded by the operating surgeon based on approximate percentage of total nuclear material. All surgical procedures were initiated with a standard 3-port, transconjunctival, 23-gauge PPV system from Alcon (Accurus Vitrectomy System, Alcon Laboratories Inc, Fort Worth, Texas, USA) after the cataract wound was examined and sutured if necessary. If retained lens material could not be efficiently removed with 23-gauge PPV alone, 1 microcannula was removed and the sclerotomy site was enlarged with a 20-gauge MVR blade. The 20-gauge port enabled the surgeon to use the ultrasonic fragmatome handpiece (Alcon Laboratories Inc) to remove any remaining lens fragments.
Twenty eyes of 20 patients underwent PPV for retained lens material following complicated cataract surgery (see Table ). The initial surgery in every case was small-incision phacoemulsification for a visually significant cataract. The mean follow-up duration was 16 weeks (range 5 to 32 weeks). An intraocular lens was placed at the time of the initial surgery in 17 eyes. Three eyes were left aphakic after their initial surgery and a secondary intraocular lens was placed during their second surgery. One patient presented with a subluxed intraocular lens that was repositioned and another had a dislocated intraocular lens that was removed and exchanged for an anterior chamber intraocular lens. One eye underwent panretinal endolaser photocoagulation during PPV for proliferative diabetic retinopathy and 1 eye had a concurrent retinal detachment that was repaired at the time of surgery.
|Patient||First Surgery||Indication for Second Surgery||Percent of Nuclear Material||Second Surgery||Preoperative VA||Preoperative IOP||Follow-up Interval||Final VA||Final IOP||Comment|
|23-Gauge Pars Plana Vitrectomy|
|1||CE/IOL||RLM||0||23-G PPV||CF 6 ft||20||N/A||N/A||N/A|
|2||CE/IOL||RLM||0||23-G PPV||CF 3 ft||20||6 months||20/50||13||CME|
|3||CE||RLM, aphakia||0||23-G PPV, ACIOL||CF face||38||2 months||CF face||17|
|4||CE/IOL||RLM, subluxed IOL||<10||23-G PPV, IOL repositioning||20/60||14||2 months||20/30||16|
|5||CE/IOL||RLM||<10||23-G PPV, AC washout||HM||N/A||6 months||20/400||16|
|6||CE/IOL||RLM||<10||23-G PPV||20/80||29||6 months||20/30||18||Increased IOP, trabeculectomy|
|7||CE/IOL||RLM||<10||23-G PPV||CF 3 ft||36||5 months||20/25||18||Uveitis|
|9||CE||RLM, aphakia||30||23-G PPV, ACIOL||CF 1 ft||12||2 months||20/25||14|
|10||CE/IOL||RLM||40||23-G PPV||CF 1 ft||44||1 month||CF 3 ft||30||CME|
|11||CE/IOL||RLM||70||23-G PPV||CF face||22||4 months||20/30||12|
|12||CE/IOL||RLM, PDR||75||23-G PPV, PRP||20/200||24||5 months||20/60||15||POAG|
|23-Gauge Pars Plana Vitrectomy With 20-Gauge Fragmatome|
|13||CE/IOL||RLM, dislocated IOL||<10||23-G PPV, 20-G Frag, IOL exchange||20/200||13||4 months||20/70||16||Dry ARMD|
|14||CE/IOL||RLM||50||23-G PPV/PPL, 20-G Frag||20/200||18||7 months||20/30||10||Dry ARMD|
|15||CE/IOL||RLM||70||23-G PPV/PPL, 20-G Frag||20/60||46||6 months||20/70||20||CME|
|16||CE||RLM, aphakia||90||23-G PPV/PPL, 20-G Frag, sulcus IOL||CF 6 ft||40||2 months||CF 6 ft||15||RRD at 2 months postoperative|
|17||CE/IOL||RLM||90||23-G PPV/PPL, 20-G Frag||20/200||30||8 months||20/40||19|
|18||CE/IOL||RLM, RRD||90||23-G PPV/ PPL 20-G Frag, RRD repair||N/A||N/A||N/A||CF||9|
|19||CE/IOL||RLM||100||23-G PPV/PPL, 20-G Frag||20/40||20||2 months||20/40||19|
|20||CE/IOL||RLM||100||23-G PPV/PPL, 20-G Frag||20/200||22||3 months||20/30||12||Postoperative choroidal, resolved 1 month|