Eyeworld

EW RETINA 120 February 2018 Research highlight by Maxine Lipner EyeWorld Senior Contributing Writer wait longer to undergo vitrectomy may include those with smaller retained fragments, lower pressure, and less severe disease from the lens, as well as those who will be available for monitoring after surgery. Dr. Shildkrot likewise empha- sized that continued follow-up during any delay in vitrectomy is important. "We're checking these patients a day after, then a few days after." It's also important to discuss with the patient and the family ahead of time that a second surgery may be needed if the vitreous does not clear, if there's any suspicion of retinal tearing, if inflammation gets worse, or if their pressure goes up, Dr. Shildkrot said. He finds that it can be advanta- geous for both the patient and the practitioner to slightly delay the vitrectomy. Dr. Shildkrot point- ed out that if you bring a retinal surgeon into the equation, it can be disruptive to his or her schedule, and patients may feel rushed. It may be easier to put the implant in, close the eye, and have the patient see the retinal surgeon the next day and think about scheduling the procedure at a time that's mutually convenient. "If I were the patient's family, it would make me feel better that it's done without the rushed urgency, if there's no need for that," Dr. Shild- krot said. "I think that in the long term, patient satisfaction will be better with the same outcome." EW Reference 1. Peck T, et al. Timing of vitrectomy for retained lens fragments after cataract surgery. Int Ophthalmol. 2017 Sep 27. Epub ahead of print. Editors' note: The physicians have no financial interests related to their comments. Contact information Peck: tp3uz@virginia.edu Shildkrot: YS8Q@hscmail.mcc.virginia.edu outcomes were the same in terms of vision," he said. "The worst vision was seen in diabetics, and that was seen across the board." Also, in cases where there was anterior lens placement, there was an increase in adverse outcomes. Dr. Shildkrot attributes the increase in adverse outcomes to the fact that this is more complicated surgery. Dr. Peck thinks that diabetics likely didn't fare as well due to their underlying condition. "What did predict the poorer final visual acuity were more baseline variables such as underlying eye disease," he said. "That might be that it's progression of that disease rather than complica- tions of the retained lens fragment." Clinical implications In Dr. Peck's view, the main take- away from the study is that medical management can be attempted ini- tially in the right patients without doing harm. "There are patients who the surgeon doesn't think need to go directly to surgery, but they're on the fence about whether they should try medical management to see if surgery can be avoided," Dr. Peck said. Patients who could possibly "That is a great inconvenience to the patients as well as to their family members," Dr. Shildkrot said. "If you can avoid a second trip to the OR while still maintaining good out- comes, that would be the optimum scenario." Included in the retrospective study were 41 eyes that underwent vitrectomy for retained lens frag- ments from 2002 to 2015 at the University of Virginia, Dr. Peck said. "We had at least 3 months of follow-up for every patient, and the mean follow-up was approximately 2 years," Dr. Peck said. Patients were placed in one of two groups. In the early group, patients went to surgery within 7 days of the initial cataract procedure. In the second group, patients underwent vitrectomy after the first week. Results were compared between the groups. "We found that for the group that went before 7 days versus after 7 days there was no difference in final visual acuity or change in visual acuity or a need for a second surgery," he said. Dr. Shildkrot concurred. "Whether we did it within a week or waited a week or longer, the Research explores whether to try vitrectomy or medical management first I t can happen to anyone—a piece of lens fragment retained following cataract surgery. Do you go back immediately to per- form a vitrectomy to retrieve it or do you give medical management a chance first? A study published in International Ophthalmology consid- ered this. 1 While just 1% of cataract surgeries require a subsequent vitrectomy, this is a significant issue, according to Travis Peck, MD, resident, Reading Health Sys- tems, Reading, Pennsylvania. With approximately 10 million cataract surgeries performed every year, a 1% rate indicates a relatively common complication, he pointed out. "The reason we did this study is it's not clear whether the surgery to retrieve the lens fragments should be done right away or whether there should be a trial of medical management to see if surgery can be avoided," Dr. Peck said. Medical management quandary The issue is whether patients have a worse outcome if they need surgery after an attempt at medical manage- ment. "Our main goal was to see if medical management can be done without creating adverse effects," Dr. Peck said. Eugene Shildkrot, MD, assis- tant professor of ophthalmology, University of Virginia, Charlottes- ville, Virginia, pointed out that some of the patients may be sick or have minimal pressure elevation or inflammation, making it appealing to consider medical management for a time. "In our patient popula- tion, most are elderly and many of them have medical comorbidities," he said. If after cataract surgery the lens is not completely removed, you now face a second surgery either the same day or in the next day or two. Searching for the right timing for vitrectomy Ultrasound of nearly complete lens in the vitreous cavity Source: Eugene Shildkrot, MD

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