EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW CATARACT 30 by Ellen Stodola EyeWorld Staff Writer Presentation Dr. Vasavada's presentation specifi- cally discussed an alternate approach to performing anterior vitrectomy during cataract surgery. This alternate approach is pars plana vitrectomy. "In this approach, the vitrector is introduced through the pars plana route and the irrigation is kept in the anterior chamber through the corneal paracentesis," he said. "The advantage of using this approach is that when we attack the vitre- ous through the pars plana, we are pulling it downward." There is no traction on the vitreous body. Additionally, Dr. Vasavada said that retinal surgeons prefer the pars plana approach for vitrectomy because it ensures better vitreous removal. "However, in a PCR situa- tion, the greatest advantage to the cataract surgeon is that there is no enlargement of the posterior capsule defect," he said. "Thus the surgeon still has a chance to convert it into a continuous PCCC and continue with in-the-bag IOL implantation." Using the pars plana approach may at first be "daunting" to cata- ract surgeons, but Dr. Vasavada said that new technology, like newer phaco machines, better vitrectors, and sutureless trocar systems, make it easier. "All that is required as an extra step is to insert a trocar through the pars plana region, about 2.5 to 3 mm behind the limbus, and introduce the vitrector probe through this trocar," he said. "The irrigation still continues to come from above through the limbal route." Dr. Vasavada's presentation looked at several cases where a pars plana vitrectomy was able to prevent further enlargement of a small PCR. EW Editors' note: Dr. Vasavada has financial interests with Alcon (Fort Worth, Texas). Contact information Vasavada: contact@raghudeepeyehospital.com managing vitreous disturbance in a PCR," he said after the meeting. "Traditionally, anterior segment surgeons are most comfortable working in their familiar territory— the anterior chamber." In the event of a PCR with sub- sequent vitreous loss, the primary aim for any cataract surgeon is to safely implant an IOL in the eye, preferably in the capsular bag, he said. "For this, it is essential that if the PCR is of a small size and rela- tively central in location, its further extension should be prevented." It is only after stopping further extension that the surgeon can attempt to convert the PCR into a continuous posterior capsulorhexis and implant the IOL in the bag. "Further, it is crucial to remove any vitreous that has prolapsed into the anterior chamber to avoid later postoperative consequences," Dr. Vasavada said. What does the audience response mean? Most cataract surgeons have been performing and still prefer to per- form bimanual anterior vitrectomy to remove the prolapsed vitreous from the anterior chamber, Dr. Vasavada said. This is reflected in the poll results. "However, the disadvantage with using this approach is that the prolapsed vitreous strands are attached to the vitreous base and vitreous body," he said. "Therefore, cutting them 'from top' would result in traction on the vitreous body behind the posterior capsule." As a result of the upward pull exerted on the vitreous body, there is forward movement of the entire vitreous body, which in turn leads to enlargement of the PCR, Dr. Vasavada said. The end result is that the surgeon ends up with a posterior capsule defect larger than the original PCR, which can jeopar- dize the final goal of a stable in-the- bag IOL placement. Pars plana vitrectomy may help with vitreous removal A bhay Vasavada, MS, FRCS, Raghudeep Eye Hospital, Ahmedabad, India, focused his presentation at the "Cataract Dilemmas" symposium at the 2014 ASCRS•ASOA Symposium & Congress in Boston on anterior limbal vitrectomy versus pars plana vitrectomy. He suggested pars plana vitrectomy as an alternate approach for surgeons during cataract surgery. Audience results An audience poll asked how those in attendance would deal with vitreous loss, with the choices being to perform a localized Weck-Cel vitrectomy, perform an anterior vit- rectomy through 1 incision, perform a bimanual anterior vitrectomy, or perform a bimanual pars plana vitrectomy. Results from 117 people were overwhelmingly in favor of the bimanual anterior vitrectomy, with more than 70% choosing this option. Just over 20% said they would choose an anterior vitrectomy through 1 incision, while about 6% chose a bimanual pars plana vit- rectomy, and about 2.6% said they would perform a localized Weck-Cel vitrectomy. According to the audience's response, 70% of the respondents said they would perform a biman- ual anterior vitrectomy in case of a posterior capsule rupture (PCR), Dr. Vasavada said. "This is in line with the current trend among cataract surgeons for At the ASCRS•ASOA Symposium & Congress this past spring, the Cataract Clinical Committee hosted a sympo- sium on cataract dilemmas that includ- ed many interesting, controversial, and hot topics. Each talk or topic will be featured throughout the fall and winter issues of EyeWorld, showcasing the talk itself, audience response questions from the symposium, and an exclusive inter- view with the speaker or speakers. In this article, Abhay Vasavada, MS, FRCS, a world-renowned ophthalmologist from India, discusses his recommended approach to dealing with vitreous loss. Of interest is the audience response question, with 70% of respondents answering that they would split irrigation and aspiration and perform a bimanual anterior vitrec- tomy, and 6% performing a bimanual pars plana anterior vitrectomy. Of note, about 23% would approach the vitreous through one incision only or with a Weck-Cel, which is not necessarily the most efficient or thorough way to clean up vitreous. I hope our readers will take interest in reading Dr. Vasavada's thoughts on this controversial subject, and perhaps consider modifying their current techniques or expanding their surgical portfolio. –Rosa Braga-Mele, MD, ASCRS Cataract Clinical Committee chair Anterior limbal vitrectomy vs. pars plana vitrectomy An audience poll asked how those in attendance would deal with vitreous loss. Source: ASCRS November 2014 "In a PCR situation, the greatest advantage to the cataract surgeon [of pars plana vitrectomy] is that there is no enlargement of the posterior capsule defect." – Abhay Vasavada, MS, FRCS