Based on presentation by Dr. Armin Wolf, Ludwig-Maximilians-University of Munich (LMU) Eye Clinic, Munich, Germany, on “Combined Phaco-vitrectomy: Killing 2 birds with One Stone”.
Scenarios where patients present with dual pathologies, like cataract and posterior segment disease, are not uncommon. Dr. Armin Wolf, Ludwig-Maximilians-University of Munich (LMU) Eye Clinic, Munich, Germany, shared insights into surgical options when managing patients presenting with these cataract and posterior segment pathologies. Available options, Dr. Wolf noted, are a sequential surgery (i.e. cataract surgery and subsequent vitrectomy or vice versa), or a one-step combination of cataract surgery and vitrectomy (i.e. phaco-vitrectomy).
While discussing disadvantages of combined phaco-vitrectomy, Dr. Wolf noted that there is sufficient data showing postoperative inflammation, especially in young diabetic patients. However, these data, he cautioned, are from studies conducted over 20 years ago and surgical techniques have evolved remarkably since then. Additional consideration should be given to possible higher risks of biometric and IOL errors following combined phaco-vitrectomy as compared to a sequential approach.
So why should phaco-vitrectomy be the preferred option? One argument, according to Dr. Wolf, is that vitrectomy-induced cataract is almost inevitable with age, therefore a combined approach solves this beforehand. In addition, Dr. Wolf said: “Increased patient costs of two or more different surgeries and logistic challenges of referral from and a cataract to a retinal surgeon are important reasons why a combined approach could be more patient friendly.” Furthermore, a combined procedure allows for optimal anterior vitreous resection during vitrectomy, which might be difficult during vitrectomy alone.
Published studies discussed by Dr. Wolf showed that, compared with sequential surgery, phaco-vitrectomy showed no differences in both clinical outcomes and in surgical success rates. The advent of modern imaging techniques has had profound influence on combined phaco-vitrectomy allowing better evaluation of biometric and functional results.
Considering available literature, Dr. Wolf noted that “the predictive error of combined vitrectomy remains high”. In addition, Dr. Wolf emphasized: “ERM detection is vital towards the surgical planning given its association with a higher risk of axial length measurement errors and possible higher risk of central macular edema in cataract surgery.” Furthermore, he added that sequential surgery may still be an option, but it’s important to note that up to 20% of those patients may not require vitrectomy after cataract surgery. “Therefore, individual evaluation of each patient is key in deciding between a combined and sequential approach,” he concluded.
Based on presentation by Dr. Andreas Stahl, Eye Centre, University of Freiburg, Germany, on “Intraoperative OCT Remains Useful in VR Surgery”.
“The iOCT is very useful in situations where we need to visualize a pathology while manipulating it, and not just before or after surgery.”
All vitreoretinal (VR) surgeons dream of the ideal intraoperative optical coherence tomography (iOCT) device. A device that is intuitive, with error-free handling, that can help improve intraoperative safety and surgical outcomes and more importantly, gain insights into pathology and shorten surgery time.
Do the current iOCT devices meet these criteria? Dr. Andreas Stahl of the University of Freiburg, Germany, evaluated the utility of iOCT in VR surgery. “In everyday settings, in my opinion, in routine epiretinal membrane peeling, there is little advantage with the use of iOCT,” said Dr. Stahl.
However, Dr. Stahl noted that there are special situations where the iOCT is very helpful in visualizing pathologies that underlie the clinical picture. These include macular detachment from optic pit disc, vitreal traction. “Therefore, the iOCT is very useful in situations where we need to visualize a pathology while manipulating it, and not just before or after surgery,” he said.
Dr. Stahl concluded that: “iOCT is intuitive, although it takes time to learn. It can improve intraoperative safety in selected situations. It certainly helps to gain novel insights into pathologies, but it does not necessarily lead to shorter surgery times as it needs time to set-up.”
Based on presentation by Dr. Heinrich Heimann, Royal Liverpool University Hospital, United Kingdom, on “Retinal Detachment: Who Needs a Buckle Anyway?”.
Dr. Heinrich Heimann of the Royal Liverpool University Hospital, United Kingdom, traced the evolution of retinal detachment surgery from the era of pre-buckling technique in the 1920s to the 1950s, through scleral buckling in the 60s, 80s and 90s, and to standard vitrectomy today. Today, very few surgeons are performing scleral buckling. Data from clinical studies have consistently shown superior anatomical success rates with vitrectomy. However, there is emerging data that points towards increased frequency of postoperative adverse events, and poorer visual outcomes with vitrectomy as compared to buckling.
According to Dr. Heimann, there is of late, a lot of renewed interest in scleral buckling among surgeons. He noted that in an analysis of 7000 retinal detachments surgeries performed by consultants and trainees in the United Kingdom, experts observed no difference in vitrectomy failure rates among the two groups. “However, we have seen higher rates of surgical failures of scleral buckling in trainees as compared to consultants. This means we can use this data as an argument that we need more training,” Dr. Heimann said.
Furthermore, Dr. Heimann shared success stories from the training program for vitreoretinal surgeons in Liverpool, where scleral buckling training has been reinforced. However, he noted that, compared to primary vitrectomy, scleral buckling is more difficult to teach and learn, and the anatomical result does not always appear better.
“It is known that primary vitrectomy is associated with acceptable results and the surgery is much easier. So why choose scleral buckling?” asked Dr. Heimann. To which he responded with: “If you want the best results, then you should continue to buckle. In addition, it is associated with better overall outcomes in certain situations such as in pediatric cases, and fewer secondary surgeries.”
Based on presentation by Dr. Nicolas Feltgen, University of Goettingen, Germany, on “Dead-ends in Vitreoretinal Surgery: Learning from the Past”.
Today we see many failures published in the literature by retinologists, where conclusions are made because certain procedures or techniques have reached dead-ends and no longer work. But what is a dead-end and how can surgeons recognize this? Are there historical examples that can help us recognize when we have reached a dead-end?
Dr. Nicolas Feltgen, from the University of Goettingen in Germany, demonstrated how dead-ends are reached and can be avoided, using interesting historical clinical cases. Dr. Feltgen narrated that in retinal vein occlusion, many surgical procedures have been tried in the past. Endovascular thrombolysis, first introduced in 1998, was thought to be associated with remarkable patient results and few complications, based on published data. However, these results could not be replicated in many patients and a lot of complications were recorded. However, data published 20 years ago had shown that cell proliferation and thrombus organization occurred within a few days, so early vitrectomy within two weeks is indicated.
Are collaterals good for the retina? Despite early data from radical optic neurotomy and chorio-retinal anastomoses showing improvements in patient outcomes, Dr. Feltgen noted: “Today, we know that collaterals correlate with ischemia and do not improve vision.”
In patients with diabetic macular edema, early data from the 1990s had shown interesting outcomes following removal of sub-retinal exudates. However, a review of the data from these studies revealed questionable study designs, and similar outcomes were not seen in other patient cohorts. Today, we also know that retinal tacks for Coats’ diseases are too traumatic.
“These lessons from the past have been useful today, because retinal surgeons are brave, curious and do not hesitate to admit failure,” concluded Dr. Feltgen.
Editor’s Note: PIE Magazine Issue 07 was distributed at the Joint EURETINA-ESCRS 2018 Congress, held in Vienna, Austria. Reporting for this story, “Revelations in Vitreoretinal Surgery?” also took place at EURETINA-ESCRS 2018.
