Eyeworld

JUN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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38 EW FEATURE February 2011International techniques and technology June 2012 Japan's view on cataract surgery: Combine it with vitrectomy by Matt Young EyeWorld Contributing Editor AT A GLANCE • Vitrectomy combined immediately afterward with cataract surgery is more popular than vitrectomy alone because of a visual benefit • Japan's version of Medicare also is partly responsible for the popularity of the combined procedure • "The most often seen complication in the combined phaco/vitrectomy may be the posterior synechiae" —Dr. Oshima The Stellaris PC There's so much more to combining surgery than a dropped nucleus T hink of modern cataract surgery and you might au- tomatically think of some other terms, like refractive lens exchange or simply refractive surgery. In Japan, doctors are thinking of something seemingly very different: vitrectomy. That might strike U.S. surgeons as odd given that sometimes vitrec- tomy is what's needed when cataract surgery goes wrong, resulting in posteriorly dislocated lens material that needs a surgical resolution. But in Japan, for a multitude of reasons, combined cataract and vitrectomy surgery is popular, providing benefits for both patients and surgical staff alike. Origins of combined surgery In Japan, combined cataract and vit- rectomy dates back about 20 years, before which combined procedures were not favored, said Shunji Kusaka, M.D., professor of ophthal- mology, Sakai Hospital, Kinki University Faculty of Medicine, Osaka, Japan. "At that time, people were op- posed to the idea of doing combined surgery," he said. "But [new] re- search was showing excellent re- sults." At that time, phacoemulsifica- tion was being introduced in a more widespread fashion in Japan. Mean- while, Japan's vitreoretinal surgeons were being trained as good pha- coemulsification surgeons. "On our way to training for vit- reoretinal surgery, we have to first perform phaco," said Dr. Kusaka. "After that we can do vitrectomy. For us, performing cataract surgery is an easier procedure compared to vit- rectomy. That's why we don't have any hesitation about performing si- multaneous cataract and vitrectomy surgery." Fair enough. Japan's ophthal- mologists seem well trained to per- form both procedures and at the same time. But why do so? In answering this question, Dr. Kusaka cited four important uses (in order of popularity) of the Stellaris PC (Procedural Choice) Vision En- hancement System (Bausch + Lomb, Rochester, N.Y.), which provides the ability to perform both cataract and vitreoretinal surgery on the same de- vice. The majority of procedures per- formed on that machine would be cataract surgery alone. Surgeons also can perform combined surgery— cataract surgery followed by vitrec- tomy. Then surgeons might use the device for vitrectomy alone. And fi- nally, in rare cases, surgeons could use it to perform unplanned vitrec- tomy, such as after a cataract surgery that involved a dropped nucleus. Vitrectomy combined immedi- ately afterward with cataract surgery is more popular than vitrectomy alone because of a visual benefit, Dr. Kusaka said. "If the patient is over 50, and we perform vitreous surgery only, the patient will develop cataract af- terward," Dr. Kusaka said. "But if we perform cataract and vitrectomy si- multaneously, the patient will not require surgery afterward." Yusuke Oshima, M.D., associ- ate professor of ophthalmology, The 20-gauge Stellaris Posterior Vitrectomy Pack Source (all): Bausch + Lomb Osaka University Graduate School of Medicine, Suita, Japan, agreed. "Vitreoretinal disease compli- cated with dense cataract is one of the challenging situations for vitrec- tomy because lens opacification often obscures clear fundus visibility during surgery," Dr. Oshima said. "In addition, cataract progression after lens-preserving vitrectomy is often seen in elder patients and has been recognized as one of the major vision-threatening complications after vitrectomy. These problems challenging to vitrectomy can be easily settled by performing com- bined phaco/vitrectomy." Japan's version of Medicare also is partly responsible for the popular- ity of the combined procedure. "When you do combined phaco/vitrectomy in Japan, the sur- gical expense for cataract surgery will be discounted 50% from the original cost," Dr. Oshima said. "That is, combined phaco/vitrec- tomy costs the full charge for vitrec- tomy plus only 50% of the charge for cataract surgery. Personally, com- bined phaco/vitrectomies constitute over 75% of my cases." Challenges Vitreoretinal surgeons who are familiar with cataract surgery shouldn't find phaco/vitrectomy challenging, Dr. Oshima said. "However, the posterior pathologies may sometimes make the phaco part somewhat difficult to deal with compared to simple cataract cases," Dr. Oshima said. "For example, dense vitreous hemor- rhage often obscures the red reflex from the fundus for performing the capsulorhexis. Hypotony in the longstanding retinal detachment cases often induces a deepened ante- rior chamber [AC] with floppy iris during phaco surgery even with a normal fluidics setting." Small pupil cases, dense cataracts, and shallow anterior chambers also provide challenging situations with combined surgery, just as they would for cataract sur- gery alone, he said. "There are also some considera- tions regarding how to sequence the anterior and posterior procedures in the combined surgery," Dr. Oshima said. "However, most of these con- siderations and arguments depend on surgeons' preferences." Pearls and preferences It appears surgeons have their own preferences among machines that can do combined work. "Compared to other machines there are only two available with a high cut rate: Stellaris PC and Constellation [Vision System, Alcon, Fort Worth, Texas]," Dr. Kusaka said. "The Stellaris PC machine is much more compact. It should be a little less expensive than the Constella- tion, too. Further, preparing the pro- cedure takes less time compared to the Constellation." The space-saving aspect of Stel- laris should be of great benefit to Japanese ORs. "For example, my OR is small," Dr. Kusaka said. "So we cannot have too many machines around the pa- tient. Having one compact machine is very convenient both for docs and nurses." In the case that vitrectomy has to be performed after cataract sur- gery as a measure to remedy a sub-

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