EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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34 EW FEATURE Phaco and vitrectomy January 2014 Doing the two-step: Combined phacoemulsification and pars by Maxine Lipner EyeWorld Senior Contributing Writer AT A GLANCE • Combined phacoemulsification and pars plana vitrectomy can be done by one practitioner alone or by two in tag-team steps. • With two surgeons working together, logistics are key in making the combined procedure work. • Combined procedures may spare patients from undergoing multiple surgeries over a prolonged period and may allow them to come to a final visual acuity sooner. I t's not a situation that practitioners want to just waltz into. A patient is diagnosed with a visually significant epiretinal membrane, as well as a cataract. The practitioner must then decide whether to tackle one or the other first, or proceed with a combined procedure. In this situation, J. Michael Lahey, MD, retina specialist, Kaiser Permanente Medical Center, Hayward, Calif., nearly always opts for the combined approach. "We routinely do [a combined procedure] in patients who look as though they're on their way to a cataract who are over 50 or 60 years old, depending on their lens status," Dr. Lahey said. Tap dancing solo While some practitioners use a tagteam approach for such combined cases, Dr. Lahey handles both the cataract and retinal procedures himself. "The genesis of this for us started when 20 years ago we asked cataract surgeons to come in first thing in the morning," Dr. Lahey recalled. "When they don't show up and you have the patient numbed up and you've done cataract surgery before, you go ahead and do it." After two or three times of that occurring, he decided to routinely handle both aspects of the combined procedure himself. Since then, Dr. Lahey estimates that he has performed about 4,000 combined procedures. Given his druthers, he removes the cataract first. "We try and be flexible if there's a reason, but we've gotten very good at taking out cataracts in people with poor red reflexes, and it's not a problem for us now," he said. "If someone is just starting out with the technique, I don't think it matters if you want to do the vitrectomy first." In general, he finds, however, that it improves the vitrectomy visualization and ability to maneuver anteriorly to first remove the cataract. Dr. Lahey acknowledged that a lot of practitioners still use the tagteam approach for combined procedures. But in his view having two surgeons in the room decreases the efficiency of the whole model, with one surgeon waiting around for the other to proceed. "Most retinal fellowship-trained people today should be pretty familiar with phaco," he said. "Also, the cataracts are usually softer before the vitrectomy than after." As a result, he finds that removing such lenses is not as difficult as the average cataract surgery. Two to tango Steven G. Safran, MD, Lawrenceville, N.J., finds that coordinating schedules with the other practitioner can indeed be an issue for combined procedures. "It's not always convenient for a retina surgeon and an anterior surgeon to work in the same center," Dr. Safran observed. "We've done these as combined procedures in the past but logistically it's much more difficult to get me (as the cataract practitioner) together with the retina specialist, for the sake of saving the patient a trip." In his view, many times the best thing to do if the cataract is not too severe is to first remove the epiretinal membrane and then re-evaluate the patient after this has healed. With such an approach, done in stages, it may even be possible to use a premium IOL such as a Crystalens (Bausch + Lomb, Rochester, N.Y.), Dr. Safran said, since you can then assess the patient's visual potential. Dr. Safran is more apt to consider a combined procedure in cases where the cataract has reached the point where it is obscuring the retina surgeon's view. "I do combined procedures where the cataract is really bad, and I've taken it out so that the retina guy can see to do what he needs to do," he said, adding, "However, even that can be staged." Removing an epiretinal membrane in conjunction with a cataract may result in leaky incisions that have not had time to heal. Source: Kevin M. Miller, MD Still, doing separate surgeries has its downsides, he acknowledged. A cataract patient who also has an epiretinal membrane, for example, may be disappointed with results after lens removal if the membrane is still in place. "You want to make it clear why you're doing what you're doing—that it's not the end of the road for the patient," Dr. Safran said. Also, depending on how the IOL calculations are done these may change after the surgery to remove the membrane. "If you're using the IOLMaster [Carl Zeiss Meditec, Jena, Germany], it shouldn't be too much of a change, but if you're using ultrasound, certainly it can change what your axial length measurements are," Dr. Safran said. Another clear downside of staging procedures, he pointed out, is that the patient needs to undergo two surgeries. "Doing it in one shot, the patient goes in once, gets everything done, and they're all fixed." On the other hand, logistics for combined procedures can be anything but simple, with each surgeon's equipment in tow. "I used to do this with a retina surgeon and have two machines and two microscopes in the same room," Dr. Safran said, adding. "It looked like we were going to be separating Siamese twins or something." Kevin M. Miller, MD, Kolokotrones professor of clinical ophthalmology, Jules Stein Eye Institute, Los Angeles, agreed that logistics can be difficult. "It's hard to schedule a busy retinal specialist and get a busy cataract guy in the operating room at the same time," Dr. Miller said. What's more, Dr. Miller pointed out that the patient may be better off with staged procedures. He explained that oftentimes you can't tell how much of the visual difficulty is the result of the cataract and how much is from the epiretinal membrane. "I would say more than half the time patients are quite happy with the visual improvement they get with cataract removal and then we don't have to proceed to a membrane peel. So if done in stages the patient may be spared the second procedure." The combined procedure can also be more problematic for surgeons. For example, retinal specialists may have to deal with leaky cataract incisions that have not had time to heal, he pointed out. What's more, with a combined operation the lens implant tends not to stay