Purpose
To compare visual acuity outcomes and adverse events in patients with retained lens fragments who underwent same-day versus later pars plana vitrectomy (PPV).
Design
Retrospective, interventional case series.
Methods
Single-center study evaluating all patients with retained lens fragments that underwent PPV over a 22-year period (1990 through 2011).
Results
The study included 569 eyes of 568 patients with a mean age of 74.6 years and a median follow-up of 8 months (range, 1 week to 100 months). One hundred seventeen patients (22%) underwent same-day vitrectomy, 131 patients (23%) underwent PPV within 1 week, and 321 patients (57%) underwent PPV more than 1 week later. Median time to vitrectomy in the same week group was 5 days, compared with 22 days in the delayed group. At the last examination, 61%, 63%, and 56% of patients undergoing PPV on the same day, within 1 week, and more than 1 week later, respectively, achieved best-corrected visual acuity (BCVA) of 20/40 or better ( P = .35), and 16%, 15%, and 21%, respectively, had BCVA of 20/200 or worse ( P = .29). There were no differences between groups when assessing cystoid macular edema ( P = .96), retinal detachment ( P = .096), elevated intraocular pressure ( P = .88), or suprachoroidal hemorrhage ( P = .26).
Conclusions
Patients undergoing same-day versus a later PPV (within 1 week or more than 1 week later) for retained lens fragments had similar visual acuity outcomes and complication rates. Although same-day surgery may be attractive logistically in many cases, our retrospective data suggest equivalent outcomes for surgical timing.
The incidence of retained lens fragments after cataract surgery has been reported to be between 0.1% and 1.1% in selected series. Vision-threatening complications of retained lens fragments may include chronic cystoid macular edema, glaucoma, and retinal detachment. Pars plana vitrectomy (PPV) to remove retained lens fragments reduces the rate of many of these complications; specifically, it has been reported to improve visual acuity (VA) and to reverse secondary glaucoma. Approximately 65% of patients achieve 20/40 or better best-corrected visual acuity (BCVA) after PPV, but 5% to 15% of patients incur 20/400 or worse VA.
The optimal timing of PPV for retained lens fragments has been debated. Although many studies have found VA outcomes to be similar regardless of timing, some have reported better results with same-day surgery. Other outcomes such as intraocular pressure (IOP) rates also have been reported to be better when vitreoretinal surgery follows the initial cataract surgery within 1 day. The purpose of this study was to compare BCVA outcomes and rates of adverse events in patients who underwent same-day versus later (within 1 week and more than 1 week) vitrectomy.
Methods
The study protocol was approved by the Institutional Review Board of the University of Miami Miller School of Medicine. This retrospective, interventional case series included all patients who underwent PPV for retained lens material after cataract surgery at the Bascom Palmer Eye Institute between January 1, 1990, and December 31, 2011. All patients with congenital cataract, pre-existing chronic uveitis, prior rhegmatogenous retinal detachment, tractional retinal detachment caused by diabetic retinopathy, or a history of severe trauma were excluded.
Study data were analyzed by dividing subjects into 3 groups based on timing of PPV: the same day, within 1 week, and more than 1 week after cataract surgery. All patients in the same-day group were examined and operated by a vitreoretinal faculty member in the same operating room as the original cataract surgery performed by other faculty, fellows, or residents. The initial informed consent for cataract surgery at our institution grants the primary surgeon and any consulting surgeon to treat any unforeseen conditions appropriately—including retained lens fragments—arising during the course of the surgery. Patients who underwent surgery beyond the same day were referred for an office evaluation at varying times after cataract surgery and frequently underwent PPV within a few days. These patients included those undergoing initial cataract surgery at the Bascom Palmer Eye Institute as well as referrals from other practices.
Patient charts were reviewed to obtain patient demographic information, clinical examination details, procedures, and complications. Additional data included age, gender, eye, history of prior ocular disease, time between cataract surgery and PPV, VA and complications before PPV, final intraocular lens status, postoperative VA, and complications. The current study did not have a defined protocol for using ancillary tests such as optical coherence tomography when it became readily available after 2002. Comparisons between proportions were performed with the χ 2 test, and differences between means were examined with the 1-way analysis of variance.
Results
The study comprised 569 eyes of 568 patients with a mean age of 74.6 years (standard deviation, 10.2 years) and a median follow-up after PPV of 8 months (range, 1 week to 100 months). Twenty-one eyes without follow-up BCVA recorded were excluded from the postoperative analysis. The number of study eyes in each group was as follows: 117 (21%) in the same-day group, 131 (23%) in the within 1-week group, and 321 (56%) in the more than 1-week group. The mean age of patients undergoing same-day surgery was less compared with the other 2 groups ( P = .001). There was no significant difference between groups when assessing comorbid ocular disease or length to final follow-up examination ( Table 1 ).
| Same-Day PPV | PPV Days 1 through 7 | PPV More than 7 Days Later | P Value | |
|---|---|---|---|---|
| No. of patients (%) | 117 (21) | 131 (23) | 321 (56) | |
| Mean age ± SD (y) | 71.7 ± 10.6 | 76.1 ± 10.0 | 75.1 ± 10.0 | .001 a |
| No. of men (%) | 63 (54) | 65 (49) | 162 (50) | .75 b |
| Pre-existing ocular disease, no. (%) c | 29 (25) | 22 (17) | 64 (20) | .29 b |
| Median follow-up time after PPV (mos) | 10.5 | 8.5 | 6.5 | .23 d |
| Range | 3 wks to 91 mos | 1 wk to 81 mos | 1 wk to 100 mos | |
| Median time to surgery (d) | — | 5 | 22 | <.001 d |
| Range | 1 to 7 d | 8 d to 15 y | ||
| Final lens status, no. (%) | .14 b | |||
| PCIOL | 34 (57) | 79 (77) | 157 (62) | |
| ACIOL | 21 (35) | 20 (19) | 80 (32) | |
| Aphakia | 5 (8) | 4 (4) | 16 (6) | |
| Not reported | 57 | 28 | 68 |
a One-way analysis of variance.
c Includes patients with age-related macular degeneration, advanced glaucoma, diabetic retinopathy with macular edema, and prior retinal detachment.
The median interval to PPV in the same-week group was 5 days, compared with 22 days in the more than 1-week group. The previtrectomy mean ± standard deviation logarithm of the minimal angle of resolution (logMAR) visual acuity for eyes undergoing same-week PPV and PPV more than 1 week later was 1.40 ± 0.83 logMAR (Snellen VA, approximately 20/500) and 1.22 ± 0.88 logMAR (Snellen VA, approximately 20/330), respectively ( P = .057). The IOP before PPV was more than 30 mm Hg in 53 eyes (41%) in the 1-week group and in 79 eyes (25%) in the more than 1-week group ( P = .001).
After PPV, a posterior chamber intraocular lens was present in 34 (57%) eyes in the same-day group, in 79 (77%) eyes in the 1-week group, and in 157 (62%) eyes in the more than 1-week group. Anterior chamber intraocular lenses were present in 21 (35%) eyes in the same-day group, in 20 (19%) eyes in the 1-week group, and in 80 (32%) eyes in the more than 1-week group. Five eyes (8%), 4 eyes (4%), and 16 eyes (6%), respectively, remained aphakic. None of these distributions were statistically different.
Mean logMAR visual acuity ± standard deviation at last follow-up examination for same-day, same-week, and more than 1-week eyes was 0.42 ± 0.53 logMAR (Snellen VA, approximately 20/53), 0.42 ± 0.54 logMAR (Snellen VA, approximately 20/53), and 0.53 ± 0.70 logMAR (Snellen VA, approximately 20/68; P = .095; Table 2 ). The final BCVA at last follow-up was 20/40 or better in 71 eyes (61%), 82 eyes (63%), and 179 eyes (56%) undergoing same-day, same-week, and more than 1-week later PPV ( P = .35). The BCVA was 20/200 or worse in 19 eyes (16%), 20 eyes (21%), and 67 eyes (21%; P = .29). Additionally, there were no statistically significant differences at the 3- and 6-month examinations in BCVA among the groups.
| Same-Day PPV, No. (%) | PPV Days 1 through 7, No. (%) | PPV More than 7 Days Later, No. (%) | P Value a | |
|---|---|---|---|---|
| All patients | 117 | 131 | 321 | |
| ≥20/40 | 71 (61) | 82 (63) | 179 (56) | .35 |
| ≤20/200 | 19 (16) | 20 (15) | 67 (21) | .29 a |
| Patients without pre-existing ocular disease | 88 (75) | 109 (83) | 257 (80) | |
| ≥20/40 | 56 (64) | 74 (68) | 154 (60) | .35 |
| ≤20/200 | 13 (15) | 12 (11) | 49 (19) | .15 |
When 115 eyes with pre-existing disease (age-related macular degeneration, advanced glaucoma, diabetic retinopathy with macular edema, and prior retinal detachment) were excluded from the VA analysis, there was no difference in last BCVA between groups. At the last examination, 56 (64%), 74 (68%), and 154 (60%) eyes undergoing same-day, 1-week, and more than 1-week later PPV, respectively, achieved BCVA of 20/40 or better (P = 0.35), but 13 (15%), 12 (11%), and 49 (19%) achieved BCVA of 20/200 or worse (P = 0.15).
Complications in the postvitrectomy window ( Table 3 ) occurred in 79 patients (68%), 95 patients (73%), and 223 patients (70%), respectively ( P = .68). Rates of corneal edema at last follow-up varied, occurring in 11 eyes (9%), 16 eyes (12%), and 59 eyes (19%) in each group, respectively ( P = .026). Cystoid macular edema was a frequent complication, occurring in 26 eyes (22%), 35 eyes (27%), and 89 eyes (28%) in each group ( P = .96). At last follow-up, macular edema had resolved clinically in 42%, 51%, and 54% of eyes in each group, respectively ( P = .54). However, optical coherence tomography results were not available before 2002 and were not standardized at each follow-up in the later part of the study. The rates of retinal detachments in the same-week group and in the more than 1-week later group (8% and 11%, respectively, vs 4% in the same-day group) were not statistically significant ( P = .096). The overall rate of retinal detachment for all eyes was 9%. There were no significant differences between groups in rates of elevated IOP ( P = .88) or suprachoroidal hemorrhage ( P = .26).
| Same-Day PPV, No. (%) | PPV on Days 1 through 7, No. (%) | PPV More than 7 Days Later, No. (%) | P Value a | |
|---|---|---|---|---|
| Overall complications | 79 (68) | 95 (73) | 223 (70) | .68 |
| Cystoid macular edema | 31 (27) | 35 (27) | 89 (28) | .96 |
| Corneal edema | 26 (22) | 60 (46) | 118 (37) | <.001 |
| Persistent inflammation | 51 (44) | 59 (45) | 131 (41) | .68 |
| Retinal detachment | 5 (4) | 11 (8) | 35 (11) | .096 |
| Elevated IOP (>30 mm Hg) | 6 (5) | 7 (5) | 14 (4) | .88 |
| Vitreous hemorrhage | 4 (3) | 5 (4) | 7 (2) | .57 |
| Suprachoroidal hemorrhage | 4 (3) | 1 (1) | 5 (2) | .26 |
The BCVA was worse than 20/40 in 170 eyes (37%) at the final examination. For eyes with severe vision loss (BCVA ≤ 20/200), the most common causes of decreased vision was pre-existing ocular conditions (30%), cystoid macular edema (19%), and pre-existing retinal detachment (16%).
There were 206 cases of PPV for retained lens fragments performed between 1990 and 1997, 175 cases performed between 1998 and 2004, and 209 cases performed between 2005 and 2011. The rates of same-day PPV in these periods increased from 8% to 12% to 40%, respectively ( P < .001). An annual analysis of cases is listed in Table 4 . Still, there were no statistically significant differences in logMAR VA at the last visit ( P = .30) between these periods. However, rates of any complication decreased from 156 (77%) in the earliest period to 112 (69%) in the middle period to 129 (63%) in the most recent period ( P = .003, test of linear trend in proportions).
