Purpose
To compare the functional and the anatomic outcomes of a combined surgery and consecutive surgery for macular hole and cataract extraction.
Design
Multicenter, retrospective, comparative case series.
Patients
One hundred twenty patients (120 eyes) with an idiopathic macular hole and cataract were operated on in 1 or 2 sessions in 2 academic centers, Dijon University Hospital and Nancy University Hospital. Combined surgery (n = 64) and consecutive surgery (n = 56) were performed between 2006 and 2007. All patients underwent pars plana vitrectomy with internal limiting membrane peeling and gas tamponade. Cataract extraction was performed with phacoemulsification followed by a posterior chamber intraocular lens implantation. The main outcome measures were near and far visual acuity at 6 and 12 months, and the rate of closure of macular hole 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). However the improvement of far visual acuity was not significant in the consecutive surgery group at 6 months ( P = .06) while such an improvement was observed in the combined surgery group ( P < .0001). The rates of closure, 100% and 96% in the combined and the consecutive groups respectively, and the complications did not differ significantly between groups.
Conclusion
Both combined and consecutive surgeries are safe and effective methods to treat macular hole and cataract with equivalent functional and anatomic results in both procedures. However, combined surgery shortened the delay for visual recovery.
Full-thickness macular hole surgery has dramatically increased over the last 10 years since the first description by Kelly and Wendel, with a closure rate higher than 90% in most recent studies. Various authors have recently tried to define tailor-made surgery to improve the closure rate while attenuating the inconvenience of postoperative position restrictions. The most common complication of vitreoretinal surgery in phakic eyes is nuclear sclerotic cataract progression, which frequently leads to cataract extraction within 2 years following the vitrectomy performed during macular hole surgery. Other complications are rare but can be severe, especially in cases of retinal detachment.
Macular holes are commonly found in older patients. Some eyes have concurrent idiopathic macular hole and cataract, making vitrectomy surgery more difficult because of blurred media. Combined cataract extraction and vitrectomy has long been described as a valid treatment for various vitreoretinal disorders. The purpose of this study was to assess the functional and anatomic outcomes of cataract and idiopathic macular hole surgery in combined and consecutive surgeries.
Material and Methods
A retrospective nonrandomized clinical case series study collected data on 120 consecutive eyes of 120 patients undergoing macular surgery in 2 academic centers between January 2, 2006 and December 31, 2007. The surgical indication was stage 2, 3, or 4 idiopathic macular hole according to the Gass classification and confirmed by optical coherence tomography (OCT). All patients had symptomatic visual loss and needed vitrectomy for macular hole treatment. All patients consented to surgery after a discussion of the risks and benefits of the surgical procedure and gave their written consent before surgery. Patients suffering from macular hole secondary to trauma or associated with simultaneous retinal detachment (RD) were excluded. Diabetic retinopathy, glaucoma, age-related macular degeneration, myopia greater than 6 diopters, and preoperative pseudophakia were exclusion criteria as well.
Patients were divided into 2 groups: the combined group, which underwent combined surgery for macular hole and cataract extraction, and the consecutive group, which underwent the 2 successive procedures. The indication for combined surgery was left to the judgment of the surgeon, based on preoperative far visual acuity and difficulty of obtaining a good vision of the macula. The patients’ medical records were reviewed and the data collected included patient age, gender, stage of the macular hole, symptom duration before surgery, and preoperative and postoperative near and far visual acuity measured with projected-light Snellen charts converted to logarithm of minimal angle of resolution (logMAR). The patients were refracted at each visit with the best correction to obtain best-corrected visual acuity (BCVA). Intraocular pressure was measured with a calibrated Goldmann tonometer. An OCT examination of the macula was performed (Stratus OCT III; Carl Zeiss Meditec, Dublin, California, USA) (macular thickness map protocol) with determination of macular hole diameter. Six radial scans were performed and the largest diameter was measured using calipers and recorded for analysis. A careful peripheral retina examination before the surgical procedure was done with a wide-field lens. Finally, the type of gas used as well as the intraoperative and postoperative complications for both groups were studied. Patients were examined at 1, 6, and 12 months postoperatively and more frequently if necessary. Cataract extraction was performed during the 1-year postoperative follow-up in the consecutive group. We took into consideration the 6-month and 1-year postoperative BCVA in both groups to compare functional results.
The surgical technique consisted of an extensive 3-port pars plana vitrectomy using a 20-gauge instrument with peristaltic or venturi pump with maximum depression set between 250 and 400 mm Hg as per the surgeon’s preferences. A posterior vitreous detachment was created in case of type 2 and 3 macular hole and then the vitrectomy was enlarged with a wide-angle viewing system (Oculus, Wetzlar, Germany). The internal limiting membrane was systematically removed without any staining agent. At the end of the procedure, the retinal periphery was examined with a wide-angle viewing system with indentation. In case of macular hole surgery alone, a complete fluid–air exchange was performed at this stage. If a retinal break was present, cryotherapy was performed under air. The gases used were SF6 (70 cases), C2F6 (49 cases), or C3F8 (1 case), as per the surgeon’s preferences.
In case of combined surgery, cataract surgery was performed just after internal limiting membrane peeling and vitrectomy enlargement and before fluid–gas exchange. The infusion was closed but kept in place and other sclerotomies were plugged. The lens was then removed by phacoemulsification and a posterior chamber intraocular lens (IOL) was inserted into the bag. All the patients received the same intraocular lens, an Acrysof MA50 BM (Alcon Laboratories, Fort Worth, Texas, USA). Postoperatively, all the patients were instructed to keep a face-down position for 1 week for at least 10 hours a day. Patients were asked to avoid the prone position during sleeping. Standard topical anti-inflammatory, antibiotic, and hypotensive treatments were prescribed for 4 weeks after the surgery. Miotics were prescribed in case of combined surgery for 3 days in order to prevent a pupillary capture.
The study’s endpoints were far and near visual acuity before surgery and at the 6-month and 1-year follow-up visits, and the closure rate at the 1-month and 12-month follow-up visits. All serious postoperative complications were collected as well. Data were analyzed using the Wilcoxon signed rank test, the Mann-Whitney test, and the Fisher exact test depending on the variables. The threshold of statistical significance was set at P < .05 and the tests were 2-tailed.
Results
Far and near visual acuities improved significantly in both groups at 12 months ( P < .0001). The 6-month postoperative BCVA significantly improved in the combined group ( P < .0001) but not in the consecutive group ( P = .06). BCVA improvement was significantly different between the 2 groups at 6 months ( P < .0001), whereas it was no longer significant at 12 months ( P = .36) ( Figures 1 and 2 ). Indeed, the progression of the BCVA during the first year after macular hole surgery was different in both groups: with the combined procedure, BCVA significantly improved during the first 6 months and then progressed slowly until the first year, with a nonsignificant improvement between 6 and 12 months. With the consecutive procedures, BCVA improvement was significant only after cataract extraction ( P < .0001).
The overall closure rate was 98.3% at 1 month. Sixty-four of the 64 macular holes (n=130; 100%) were closed after 1 surgical procedure in the combined group compared to 54 of 56 macular holes (96%) in the consecutive group, P = .22. The final overall macular hole closure rate was unchanged at 1 year.
The characteristics of our population are displayed in the Table . The age of the patients ranged from 54 to 90 years (mean, 71 years) and the follow-up ranged from 12 to 18 months (mean, 13.5 months). The duration of the symptoms prior to surgery ranged from 1 to 36 months (mean, 7.37 months). The preoperative macular hole was graded as stage 2 (17 eyes), stage 3 (76 eyes), or stage 4 (27 eyes) using the Gass classification, with no statistically significant difference between the 2 groups.
| Combined Surgery | Consecutive Surgery | ||
|---|---|---|---|
| n = 64 | n = 56 | P | |
| Gender (M/F) | 22/42 | 18/38 | .85 |
| Age (years) a | 70.4 ± 6.6 | 71.8 ± 7.3 | .24 |
| Duration of idiopathic MH (months) | 7.2 ± 5.6 | 7.5 ± 4.6 | .48 |
| Mean size of idiopathic MH (μm) | 453 ± 155 | 427 ± 199 | .15 |
| Mean far VA (logMAR) | |||
| Preoperative VA | 0.97 ± 0.33 | 0.92 ± 0.36 | .32 |
| Postoperative VA at 6 months | 0.43 ± 0.28 | 0.79 ± 0.32 | <.0001 |
| Postoperative VA at 12 months | 0.39 ± 0.27 | 0.42 ± 0.34 | .74 |
| Mean near VA (logMAR) | |||
| Preoperative VA | 0.90 ± 0.16 | 0.80 ± 0.20 | .72 |
| Postoperative VA at 6 months | 0.46 ± 0.22 | 0.66 ± 0.25 | <.0001 |
| Postoperative VA at 12 months | 0.44 ± 0.22 | 0.45 ± 0.28 | .60 |
| Mean far VA change | |||
| 6 months after surgery | 0.55 ± 0.40 | 0.13 ± 0.29 | <.0001 |
| 12 months after surgery | 0.58 ± 0.38 | 0.50 ± 0.38 | .36 |
| Mean near VA change | |||
| 6 months after surgery | 0.44 ± 0.24 | 0.14 ± 0.26 | <.0001 |
| 12 months after surgery | 0.46 ± 0.25 | 0.35 ± 0.29 | .06 |
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