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http://www.retinalphysician.com/printarticle.aspx?articleID=107237
SURGICAL PRECISION
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12/12/2012 20:06
Retinal Physician
http://www.retinalphysician.com/printarticle.aspx?articleID=107237
anterior chamber, can interfere with visualization, which can be a real issue with ILM peeling. If phaco is performed after PPV, the cataract may limit the view, potentially interfering with ILM peeling as well. Refractive outcomes are less predictable with phaco-vit than with phaco performed by a high-volume refractive cataract surgeon as a separate procedure on another day. This is because effective lens position is less predictable after PPV. Vitreoretinal surgeons rarely perform enough cataract surgery to be proficient in the use of toric intraocular lenses and femtosecond laserassisted cataract surgery, which are rapidly becoming the standard of care. A-scan ultrasound axial length errors are significant in the presence of epimacular membrane, macular hole, or vitreomacular membrane syndrome because the A-scan cannot calculate the axial position of the fovea after vitreomacular traction or after tangential traction is removed. If significant media opacity is present, the Humphrey IOLMaster 500 or the Haag Streit LENSTAR LS900 cannot be used because they both measure axial length from the RPE using low-coherence optical technology. Vitreomacular surgery is a relative contraindication for phaco-vit because high visual and refractive expectations driven by modern-day refractive cataract surgery cannot be reliably achieved with this surgical approach. Phaco-vit is indicated if there is a cataract sufficient to limit visualization during non elective PPV, and it is typically indicated for diabetic tractional retinal detachments, posterior vitreoretinopathy, or giant breaks. Posterior synechia are more common if gas bubbles are used, even with intermittent use of mydriatic agents. On occasion, gas may pass through the zonules into the anterior chamber, especially if the infusion cannula tip is allowed to tip anteriorly as fluid-air exchange is initiated.
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12/12/2012 20:06
Retinal Physician
http://www.retinalphysician.com/printarticle.aspx?articleID=107237
Figure 1. Posterior capsulorhexis is performed with the vitreous cutter after anterior vitrectomy to prevent engagement of vitreous in the fragmenter.
Figure 2. Cortical cleaving hydrodissection is performed with a blunt 27-g cannula attached to a 3- to 5-mL syringe via a short length of tubing. The fragmenter should be used at full power with continuous aspiration and sonification because aspiration without sonification causes plugging, and sonification without aspiration rapidly causes scleral burns. The fragmenter tip should be positioned in the equatorial plane of the lens, staying away from anterior and posterior capsule. Drilling into the lens and then pulling back while sonification is activated will allow lens material to be aspirated without plugging. Remove all of the lens capsule with end-gripping forceps with serrated teeth by zonulorhexis if there is florid neovascularization, severe inflammation, or a scleral laceration nears the pars
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12/12/2012 20:06
Retinal Physician
http://www.retinalphysician.com/printarticle.aspx?articleID=107237
plicata (Figure 3). Removal of all of the capsule is not possible using the vitreous cutter; the forceps method is safer and more effective. Removal of the entire capsule reduces cyclitic membrane formation, hypotony, phthisis, concave iris secondary to iris-capsule synechia, and capsule-anterior adherence leading to vitreous base traction.
Figure 3. Zonulorhexis is performed in a circular fashion with the ILM or end-grasping forceps. Capsule retention is indicated if there is no inflammation, infection, or neovascularization and the intent is to perform IOL implantation, either at time of surgery or at a later date. Although the intact capsule can retain silicone oil in the vitreous cavity, rapid and marked fibrous proliferation invariably occurs, rendering the capsule opaque. This technique can buy time until the oil can be removed, but often fibrous PCO is so marked that the retina can be visualized, and B-scan ultrasonic imaging is ineffective with silicone oil in the vitreous cavity.
SUMMARY
PPL is a powerful technique that must be part of the vitreoretinal surgeon's armamentarium. Use of phaco-like techniques for lensectomy is superior to traditional methods. Phaco-vit is a crucial technique for vitreoretinal surgeons but is often overutilized because of the false belief that PPV always causes cataracts. Phaco-vit simply does not provide the refractive outcomes patients expect and deserve. RP
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12/12/2012 20:06