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42 EW FEATURE Evaluating continued from page 41 For Dr. Stewart, the decision point on treatment is multifactor- ial—if the patient has lattice degen- eration and has had a posterior vitreous detachment, "then the pa- tient has a lower risk of getting a de- tachment from the cataract surgery. If there's lattice but no PVD, then there's greater concern," he said. If biomicroscopy doesn't help clarify if there's been a PVD, he recom- mended using B-scan ultrasound. Treatment strategies Three main treatments—scleral buckle, pneumatic retinopexy, and vitrectomy (with or without accom- panying buckle)—remain the stan- dard of care in treating a full-blown detachment. "Which of the three procedures is used to correct the problem de- pends on where the pathology is," Dr. Boyer said. "Most retinal special- ists lean toward doing a vitrectomy in a pseudophakic patient." Studies in Europe show pseudophakes do better after vitrec- tomy and phakics do better after scleral buckling procedures, Dr. Stewart said. "There's not a lot of extra benefit to adding a buckle to the vitrectomy," he said. Pneumatic is not as successful in pseudophakes simply because of the increased diffi- culty in getting the full periphery in that patient group, making it easier to miss small tears. "If you don't know where the tears are, you can't treat them. So it's possible to get secondary tears after pneumatic," he said. Dr. Moshfeghi said he's not likely to perform vitrectomy in a phakic patient. "First, you're likely to create a worse cataract with a vitrectomy," he said. "Primary scleral buckle is the historical and still practiced way to fix it." Additionally, scleral buckle generally does not make the cataract worse, nor will it "guarantee a cataract will form earlier, unlike a vitrectomy." Scleral buckles change the length of the eye, which in a phakic patient is not terribly crucial, as the subsequent IOL calculations will take that into account. In a pseudophake, however, "scleral buckle can render the IOL almost worthless as buckles can change re- fraction by as much as 2 or 3 D," Dr. Moshfeghi said. Unfortunately, "a lot of fellows are graduating now without learning how to perform scleral buckles, so it may be a dying art," Dr. Fawzi said. "I personally think there is a role for it in patients who are young, my- opic, who are phakic, and don't present with PVD. If we do a vitrec- tomy on them, we're guaranteeing them a cataract off the bat." Because the technology in both phaco machines and IOLs has be- come so sophisticated, more and more retinal specialists are performing straight vitrectomy and discounting the potential for wors- ening the cataract in phakic pa- tients. Post-phaco, retina specialists suggest cataract surgeons encourage patients to come in if any sign or symptom of a potential tear or de- tachment is noticed. "The more patients are aware, the more likely they'll come in if they start noticing an increase in floaters," Dr. Stewart said. EW References 1. Ripandelli G, Coppe AM, Parisi V, et al. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmology. 2007;114(4):692-7. Epub 2007 Jan 17. Editors' note: The doctors interviewed have no financial interests related to this article. Contact information Boyer: vitdoc@aol.com Moshfeghi: amoshfeghi@med.miami.edu Stewart: stewartj@vision.ucsf.edu February 2011 Retina co-morbidity for the anterior segment surgeon January 2012