EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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64 EW CATARACT March 2012 Fishing for retained lens fragments by Maxine Lipner Senior EyeWorld Contributing Editor Two views of retained lens fragments Source: Maria Stefaniotou, M.D. Weighing same-day versus delayed vitrectomy I t's one of those problems that could occur in any cataract procedure—a case of retained lens fragments. The issue then becomes one of whether to use vitrectomy to remove the fragment immediately or to wait until later when the eye has stabilized, accord- ing to Marcus H. Colyer, M.D., Retina Group of Washington, Fairfax, Va., and Washington Hospital Center, Washington, D.C. Research published in the September 2011 issue of Retina indicates that the results of pars plana vitrectomy are very similar with 29% of eyes undergoing immediate vitrectomy experiencing post-op complications versus 34% of those who delayed the procedure having trouble. There is more of an opportunity than ever for same-day manage- ment, with many cataract and reti- nal surgeons tending to perform surgery in outpatient centers next door to one another. "They would have the ability to either go into the room or have the patient moved," Dr. Colyer said. "So logistically over the past 10 years it has become eas- ier, versus in a big hospital setting, to undergo same-day vitrectomy sur- gery." With this in mind, investiga- tors questioned whether or not doing it this way is clinically help- ful. Comparing the effects Included in this consecutive case se- ries involving 172 eyes were all pa- tients who were referred to the Retina Group of Washington with a diagnosis of retained lens fragments from 2003 to 2008. "We wanted to specifically pull out those who had same-day surgery and compare them to patients who had surgery any other time," Dr. Colyer said. In those that delayed vitrectomy, the mean time to the procedure was 15 days. Investigators found that both groups fared similarly. "Immediate surgery patients had equal visual outcomes to those who had non- same-day surgery," Dr. Colyer said. "Also, the complication rates were not statistically significantly differ- ent between the two groups." Six- month logarithm of the minimum angle of resolution best corrected visual acuity was equivalent in both groups at 0.44. They determined that perform- ing same-day surgery was more of a logistical benefit. With same-day surgery, patients only have to go to the operating room and go through sedation and anesthesia one time. "There's less anxiety provoked fol- lowing the surgery knowing that they're going to have to go back into the eye," Dr. Colyer said. "There's also the theoretical benefit of re- moving the inflammatory nidus of the lens nucleus earlier as opposed to later." However, there are also poten- tial downsides for opposite reasons. Practitioners who perform same-day surgery face having an angry in- flamed eye they're operating on much sooner. "There's the potential risk of bleeding in the eye and lim- ited visualization," Dr. Colyer said. "Those are all factors that may work against you trying to do same-day [surgery]." There can also be medical-legal considerations to same-day surgery. "One big factor to consider is the role of the informed consent and whether or not the patient is con- sentable if [he/she] received any anesthesia," Dr. Colyer said. "If there's family or power of attorney available, or if the primary consent was written in such a way [to allow] any other surgery deemed necessary at the time of cataract surgery, then that would be a way around it— that the patient is as completely in- formed as possible and in agreement with the proposed procedure." Decision time Deciding whether to opt for same- day pars plana vitrectomy or to delay the procedure may come down to logistics and where the practitioner primarily operates. "Patients should not be referred at 3 o'clock in the afternoon to go across town to have their lens re- moved the same day simply because it needs to be done the same day," Dr. Colyer said. "However, if the reti- nal surgeon and the cataract surgeon are co-located and it's reasonable to do it the same day, then it's not going to harm the patient to do that." The bottom line, Dr. Colyer thinks, is that if you're in an outpa- tient surgery center and you are a cataract surgeon and have a retained lens fragment and there is a retinal surgeon who is available nearby, it would be reasonable to do a same- day procedure in most cases. There are a few instances, how- ever, where it is more prudent to wait. For example, if there's a signifi- cant amount of corneal edema or if the patient sustained a supra- choroidal hemorrhage during the cataract surgery and is either a frag- ile diabetic or an elderly patient and may not be able to stay on the table for another hour, Dr. Colyer recom- mended delaying the procedure. Going forward, he thinks that the use of the femtosecond laser for cataract surgery will be another fac- tor to consider in all this. "It will be interesting to see how the laser-as- sisted cataract surgery changes the incidence of retained lens frag- ment—if it changes the inflamma- tion related to retained lens fragments," Dr. Colyer said. "But overall I think that we've reached a steady state in how we handle those problems and the overall number of them is probably diminishing be- cause people are getting so comfort- able and good with cataract surgery." EW Editors' note: Dr. Colyer has no financial interests related to this article. Contact information Colyer: 202-782-6965, colyer_m@yahoo.com