EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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March 2013 EW RESIDENTS 131 assisted anterior vitrectomy after capsule rupture" sues. We congratulate the authors and will be on the lookout for articles that will continue to explore this topic following their lead. EW References From left to right: Tomas Aleman, M.D., Kian Eftekhari, M.D., and Hilary Brader, M.D. Source: Paul Tapino, M.D. For example, the use of triamcinolone with the increased visualization of the vitreous may lead to more extensive and aggressive anterior vitrectomy maneuvers, especially in non-experienced surgeons. One can argue that this may indirectly increase the rate in which inadvertent vitreoretinal tractions may occur with a potential increase in the rate of vitreoretinal complications. Would it be preferable to approach the vitreous prolapse through a pars plana approach, a change that may be dependent on the magnitude of the vitreous prolapse itself? Do we have to be concerned about deposition of triamcinolone crystals in the capsular bag or intraocular lens, especially near the visual axis?8 Previous studies have reported no adverse visual outcomes of such deposits in the macula following triamcinoloneassisted posterior vitrectomy,9 but their frequency and visual impact following anterior vitrectomy is yet to be determined. To which extent is the existence of complications, particularly CME and other vitreoretinal changes, a result of the violation of the anterior vitreous alone or due to the incomplete removal of the prolapsed vitreous? If the complications are predominantly a function of the amount of vitreous left inadvertently in the anterior chamber, as previous data suggest (for vitreoretinal complications), then the authors' work would predict a reduction in the frequency of such negative outcomes with the use of triamcinolone-assissted anterior vitrectomy. Their results, however, will have to stand the test of its use in larger groups of patients. Ethical issues are always a consideration in work that involves surgery as the authors astutely pointed out. But data from existing large observational studies involving cataract surgery by phacoemulsification and/or anterior vitrectomy could have been used as "historical controls" and may be used in the future to answer similar questions, perhaps without having to embark in much more difficult and time-consuming, prospective, randomized, case-control studies. The evidence so far tempts us to conclude that the use of intracameral triamcinolone is a benign and safe procedure that will facilitate visualization and removal of vitreous from the anterior chamber. However, every procedure or modifica- tion of an existing procedure, no matter how small, should be approached with caution as there is virtually no intervention that is riskfree. Thus it may be premature to reach such a conclusion. As briefly outlined above for a couple of scenarios, there are many potential unforeseen interactions that may indirectly influence the outcomes of our cataract surgeries, specifically the long-term outcomes, if triamcinolone-assisted anterior vitrectomy becomes widespread and routinely used. Larger prospective observational studies or meta-analysis of existing large observational studies may be needed to address these is- 1. Allinson RW, Metrikin DC, Fante RG. Incidence of vitreous loss among third year residents performing phacoemulsification. Ophthalmology 1992;99:726-730. 2. McPherson SD Jr., Brower SA. Anterior vitrectomy for complications of cataract extraction. Trans Am Ophthalmol Soc. 1979;77:329-38. 3. Gimbel HV. Posterior capsule tears using phacoemulsification causes, prevention and management. Eur J Implant Refract Surg 1990;2:63-69. 4. Arbisser LB, Charles S, Howcroft M, Werner L. Management of vitreous loss and dropped nucleus during cataract surgery. Ophthalmol Clin North Am. 2006;19:495-506. 5. Angunawela RI, Liyanage SE, Wong SC, Little BC. Intraocular pressure and visual outcomes following intracameral triamcinolone assisted anterior vitrectomy in complicated cataract surgery. Br J Ophthalmol. 2009;93:1691-1692. 6. Fine HF, Spaide RF. Visualization of the posterior precortical vitreous pocket in vivo with triamcinolone. Arch Ophthalmol. 2006;124:1663. 7. Gillies MC, Simpson JM, Billson FA, Luo W, Penfold P, Chua W, Mitchell P, Zhu M, Hunyor AB. Safety of an intravitreal injection of triamcinolone: results from a randomized clinical trial. Arch Ophthalmol. 2004;122:336-340. 8. Sakalar YB, Unlu K, Keklikci U, Caca I, Senol BB. Persistent triamcinolone acetonide particles on the posterior lens capsule after intravitreal injection. Ann Ophthalmol (Skokie). 2008;40:190-192. 9. Sarraf D, Vyas N, Jain A, Bui A, Kertes PJ, Freund KB, Chan C. Triamcinolone-associated crystalline maculopathy. Arch Ophthalmol. 2010;128:685-90. Contact information Tapino: Paul.Tapino@uphs.upenn.edu Send us your favorite APP! Have a favorite app that helps you with business or personal activities? Email stacy@eyeworld.org with the app name and how it helped you. Apps selected will be published in Ophthalmology Business and their submitters will receive a $50 iTunes card.