EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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130 EW RESIDENTS March 2013 EyeWorld journal club Review of "Clinical outcomes of triamcinolonephacoemulsification complicated by posterior by Tomas Aleman, M.D., Kian Eftekhari, M.D., Hilary Brader, M.D., and Paul Tapino, M.D., residency program director, Scheie Eye Institute Paul Tapino, M.D., residency program director, Scheie Eye Institute, University of Pennsylvania This month, an interesting study on triamcinolone-assisted anterior vitrectomy is published in JCRS. These studies are difficult to do, and I asked the U Penn residents to review this paper. David F. Chang, M.D., chief medical editor P osterior capsular rupture is a feared complication of cataract surgery. This is especially relevant for residents as they have a higher rate during their training.1 Learning how to prevent rupture of the posterior capsule and preparing for it preoperatively are part of the training of every cataract surgeon.2 However, deciding on a management strategy once it has happened is controversial and is dependent on the individual surgeon's training and preference. Damage to the anterior vitreoretinal barrier after a posterior capsular break is known to increase the frequency of postop complications of cataract surgery.3 Among them is an increased rate of endophthalmitis, rhegmatogenous retinal detachments, and cystoid macular edema.4 Incomplete removal of prolapsed vitreous from the anterior chamber further in- Clinical outcomes of triamcinolone-assisted anterior vitrectomy after phacoemulsification complicated by posterior capsule rupture Shivani Kasbekar, M.B. Ch.B., M.Sc., Som Prasad, M.S., F.R.C.S., F.A.C.S., F.R.C.Ophth., Balakrishna Vineeth Kumar, F.R.C.S.Ed.(Ophth) J Cataract Refract Surg (March) 2013; 39:414-418. Purpose: To compare the clinical outcomes in patients who had triamcinolone acetate-assisted anterior vitrectomy and patients who had anterior vitrectomy without triamcinolone acetate after phacoemulsification complicated by posterior capsule rupture and vitreous loss. Setting: Arrowe Park Hospital, Wirral, United Kingdom. Design: Retrospective consecutive case note review. Methods: Consecutive case notes of patients who had anterior vitrectomy assisted by triamcinolone acetonide (triamcinolone group) or without triamcinolone acetate (no-triamcinolone group) after posterior capsule rupture from January 2007 and January 2011 were identified and examined. Data recorded at the clinic visit preoperatively and one day and three months postoperatively were collated. Information recorded on the pro forma included visual acuity, ocular comorbidities, intraocular pressure (IOP), vitreous strands in the anterior chamber, and other adverse events. Results: No statistically significant difference was found in the visual acuity or IOP between 17 patients in the triamcinolone group and 34 patients in the no-triamcinolone group at any time point. Vitreous strands in the anterior chamber were noted in one patient in the triamcinolone group and seven patients in the no-triamcinolone group. Cystoid macular edema (CME) was present in three patients in the no-triamcinolone group, including one patient with vitreomacular traction. Conclusions: There was no significant increase in IOP after triamcinolone acetate-assisted anterior vitrectomy. Higher rates of CME and residual anterior chamber vitreous strands in the no-triamcinolone acetate group support the clinical use of triamcinolone acetate. Financial disclosure: No author has a financial or proprietary interest in any material or method mentioned. creases the frequency of such complications and can by itself lead to persistent intraocular inflammation, IOP elevations and vitreocorneal contact with corneal edema, all of which can impact the final visual outcome. It is thus critical that appropriate removal of the prolapsed vitreous occurs following this complication. Difficult visualization of an otherwise mostly transparent structure has long challenged vitreoretinal surgeons and prompted the use of diverse solutions that make the vitreous visible to the surgeon. The literature on such maneuvers in posterior segment surgery is abundant but comparatively scarce regarding its use in anterior segment vitrectomy.5,6,7 In the March issue of the Journal of Cataract & Refractive Surgery, Kasbekar et al. report their experience using triamcinolone acetonide during anterior vitrectomy in cataract surgery complicated by posterior capsular rupture with vitreous prolapse into the anterior chamber. The authors should be commended as this is the first study in which the use of triamcinolone acetonide during anterior vitrectomy was compared to a control group in which triamcinolone was not used. Their work was a retrospective, case-control study. They reviewed the preand postop records of patients from their own practice who had posterior capsular rupture with vitreous prolapse into the anterior chamber during phacoemulsification. They compared the outcomes in patients who had anterior vitrectomy with (n=17) versus without (their control group, n= 34) the use of intracameral triamcinolone acetonide. Patients with incomplete records were excluded. The groups were not matched for age or ocular comorbidities, which is understandable given the retrospective design. There was consistency among the surgeons who chose to use triamcinolone acetate; Kenalog 40 mg/mL was diluted in a 1:1 ratio with balanced salt solution and injected into the anterior chamber before the anterior vitrectomy began but after the posterior capsular rupture was identified. They then proceeded with vitrectomy and attempted to remove all vitreous strands before washing out the excess triamcinolone acetonide with balanced salt solution. All patients, whether they had triamcinolone or not, had an intraocular lens placed in the sulcus or capsular bag. Their postop regimen included an antibiotic and a steroid drop. The authors compared postop best corrected visual acuity, intraocular pressure (IOP), presence of vitreous strands and/or cystoid macular edema (CME) between the two groups. They found no statistically significant difference between the postop best corrected visual acuity or IOP between the two groups. Of note, there was a relatively larger improvement in visual acuity in the no-triamcinolone (1.13 to 0.29 logMAR) compared to the triamcinolone (0.74 to 0.13 logMAR) group. The significance of this difference is hard to explain with the data presented and may reflect different baseline characteristics between the groups, which could not be matched in this setting. There was also a trend toward higher IOP at oneweek postop in the triamcinolone group compared to the control, a difference that disappeared three months after the surgery. Vitreous strands were noted post-op in 1/17 patient in the triamcinolone group and in 7/34 patients in the no-triamcinolone group. This was also not statistically significant but appears to be the most salient of the differences found. CME was identified in three patients in the no-triamcinolone group postop, two of which were found to be in association with a branch vein occlusion and with vitreomacular traction. The relevance of this postop complication is unclear given the small sample size and the fact that there is no indication that a systematic search, either with fluorescein angiography or with optical coherence tomography, for this complication ever occurred in every patient from each group. Again, this is also understandable given the design of this study. The small sample size or the retrospective nature of this study, both recognized by the authors as limitations, should not overshadow the fact that this work will serve as the starting point for larger prospective inquiries into this topic. The work also raises a number of important questions that need to be addressed.