Purpose
To assess the functional and anatomic outcomes of cataract and idiopathic epiretinal macular membrane extraction in combined and consecutive surgeries.
Design
Multicenter, retrospective, comparative case series.
Methods
One hundred seventy-four patients (174 eyes) with an epiretinal macular membrane (ERM) and cataract were operated on in 1 or 2 sessions in 2 academic centers, Dijon University Hospital and Nancy University Hospital. Combined surgery (n = 109) and consecutive surgery (n = 65) were performed between 2005 and 2006. All patients underwent ERM and internal limiting membrane removal. Cataract extraction was performed with phacoemulsification followed by a posterior chamber intraocular lens implantation. The main outcome measures were near and far visual acuity and central macular thickness evaluated with optical coherence tomography.
Results
After a 12-month follow-up, the postoperative best-corrected visual acuities significantly improved in both the combined and the consecutive surgery groups (near and far vision in both groups, P < .0001). Similarly, the postoperative macular thickness significantly decreased in both groups ( P < .0001). We noted no statistical differences between the visual acuity improvement in both groups (near vision, P = .54; far vision, P = .38). However, visual acuity recovery was quicker in the combined surgery group.
Conclusions
Combined and consecutive surgeries are effective procedures to treat idiopathic ERM. The functional and anatomic results are equivalent in both procedures.
The number of macular surgeries has increased dramatically over the last 10 years, and many authors have reported different procedures for the treatment of epiretinal macular membranes (ERMs). ERM surgery has been shown to improve visual acuity in 80% to 90% of cases, and the debate on the advantages and the safety of different surgical options to treat the ERMs continues.
The most frequently reported complication of ERM removal is cataract progression, which frequently requires surgical treatment within the 2 years after the vitrectomy performed for idiopathic ERM surgery. Other complications are rare, but their consequences could be severe, especially in cases of retinal detachment (RD).
ERMs are found most commonly in older patients. Because ERM disease is related to aging, some eyes have concurrent idiopathic ERM and cataract, making vitrectomy surgery more difficult, with blurred media. Combined cataract extraction and vitrectomy has long been described as treatment for various vitreoretinal disorders, but ERM is probably one of the most popular indications. The purpose of this study was to assess the functional and anatomic outcome of cataract and idiopathic ERM extraction in combined and consecutive surgeries.
Methods
A retrospective, nonrandomized clinical case series study collected data on 174 consecutive eyes of 174 patients undergoing macular surgery in 2 academic centers between January 2005 and December 2006. Patients with ERM secondary to uveitis or trauma or associated with simultaneous RD were excluded. Diabetic retinopathy, glaucoma, age-related macular degeneration, and myopia of more than 6 diopters were exclusion criteria as well. We treated 109 eyes with a combined procedure (combined group) and 65 eyes with consecutive surgery (membrane surgery and cataract surgery performed separately; consecutive group).
All patients had symptomatic visual loss and needed vitrectomy for ERM removal. All patients consented to surgery after a discussion of the risks and benefits of the surgical procedure and gave their written consent before surgery.
All patients underwent near and far visual acuity measurements using projected-light Snellen charts converted to logarithm of minimal angle of resolution units. The patients were refracted at each visit with the best correction. Intraocular pressure was measured with a calibrated Goldmann tonometer, an optical coherence tomography (OCT) examination of the macula was performed (Stratus OCT III; Carl Zeiss Meditec, Dublin, California, USA; macular thickness map protocol), and a careful peripheral retina examination before the surgical procedure was carried out. If a retinal break was observed before the procedure, argon laser photocoagulation was performed before surgery. All the patients were examined at 4 follow-up visits: 1 week, 1 month, 6 months, and 1 year after the initial surgery. Additional examinations were performed when needed. OCT was performed at 1 month, 6 months, and 1 year after ERM surgery in both groups. Cataract extraction was performed during the 1-year postoperative follow-up for the consecutive group. We took into consideration the 1-year postoperative OCT in both groups to compare central macular thickness.
Eyes with ERMs underwent minimal central 3-port pars plana vitrectomy using 20-gauge instrumentation, either a peristaltic or venturi pump, with maximum depression set between 250 and 400 mm Hg according to the surgeon’s preference. Most eyes (92%) had a posterior vitreous detachment at the time of surgery. A posterior vitreous detachment was created if not present. Then, microforceps were used to lift the edge of the ERM. If no edge was identified, the membrane was grasped directly approximately 2 mm from the fovea and detached circularly. Then the ILM was removed systematically without using dye. At the end of the procedure, the retinal periphery was examined with a wide-angle system and indentation. If an untreated retinal break was present, cryotherapy was performed. If an RD was observed during the surgical procedure, the vitrectomy was enlarged and the subretinal fluid was drained through the break before an intraocular tamponade procedure with SF 6 . Then, the retinal break was treated with cryotherapy.
One hundred nine procedures (109 eyes) were associated with phacoemulsification and intraocular lens implantation (combined surgery). In all combined cases, cataract surgery was performed after the ERM removal. Briefly, phacoemulsification with posterior chamber intraocular lens implantation was performed while the infusion was closed but kept in place and other sclerotomies were sutured. All the patients received the same intraocular IOL, an AcrySof MA50 BM (Alcon Laboratories, Fort Worth, Texas, USA). After the cataract extraction was performed, the last sclerotomy was sutured.
All serious postoperative complications were recorded, and functional and anatomic results were analyzed. End points were near and far visual acuity and the central macular thickness measured with OCT for these procedures before the surgery and at the 6-month and 1-year follow-up visits.
Data were analyzed using the Wilcoxon signed-rank test, the Mann–Whitney U test, and the Fisher exact test depending on the variables. A linear regression was performed between baseline and final visual acuity. The threshold of statistical significance was set at P < .05 and the tests were 2 tailed.
Results
Preoperative far and near visual acuities in both groups were statistically comparable. The 12-month postoperative best-corrected visual acuities significantly improved in both groups (near and far vision, P < .0001). However, the time required to recover was different in the 2 groups ( Figures 1 and 2 ). The 6-month postoperative best-corrected far visual acuities improved significantly in the combined group ( P < .001), but not in the consecutive group ( P = .31). The 6-month postoperative best-corrected near visual acuities improved significantly in both groups ( P < .01). Although the best-corrected far visual acuity reached a statistically significant difference between the 2 groups at 12 months ( P = .02), we did not find any statistical difference in visual acuity improvement when comparing the 2 groups at 12 months (near vision, P = .54; far vision, P = .38).
The age of the patients ranged from 47 to 86 years (mean, 71.9 years), and the follow-up ranged from 12 to 18 months (mean, 12.7 months). The postoperative macular thickness decreased significantly in both groups ( P < .0001). The mean postoperative foveal thickness decreased less in the combined group than in the consecutive group (85 μm vs 104 μm) at 12 months, but these results did not reach statistical significance ( P = .13). The characteristics of these 2 groups are listed in the Table .
| Combined Group (n = 109) | Consecutive Group (n = 65) | P Value | |
|---|---|---|---|
| Age (yrs) a | 72.7 ± 5.5 | 70.5 ± 9.7 | .03 |
| Ratio (male/female) | 43/66 | 31/34 | .34 |
| Right eye/left eye | 59/50 | 31/34 | .44 |
| Mean far VA | |||
| Before surgery | 0.61 | 0.56 | .22 |
| 6 months after surgery | 0.39 | 0.54 | <.0001 |
| 12 months after surgery | 0.37 | 0.31 | .02 |
| Mean near VA | |||
| Before surgery | 0.61 | 0.58 | .58 |
| 6 months after surgery | 0.36 | 0.34 | .74 |
| 12 months after surgery | 0.35 | 0.33 | .73 |
| Mean far VA change | |||
| 6 months after surgery | 0.22 | 0.02 | <.0001 |
| 12 months after surgery | 0.25 | 0.26 | .38 |
| Mean near VA change | |||
| 6 months after surgery | 0.24 | 0.23 | .75 |
| 12 months after surgery | 0.25 | 0.26 | .54 |
| Mean foveal thickness (μm) a | |||
| Before surgery | 406 ± 74 | 416 ± 84 | .48 |
| 6 months after surgery | 328 ± 49 | 318 ± 41 | .25 |
| 12 months after surgery | 321 ± 47 | 312 ± 40 | .21 |
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