In this issue of Retina Today, Claus Eckardt, MD, discusses his surgical approach to phacovitrectomy and the advantages and disadvantages of this combined procedure.

We extend an invitation to readers to submit pearls for publication in Retina Today. Please send submissions for consideration to Dean Eliott, MD (dean_eliott@meei.harvard.edu); or Ingrid U. Scott, MD, MPH (iscott@hmc.psu.edu). We look forward to hearing from you.
— Dean Eliott, MD; and Ingrid U. Scott, MD, MPH

It is well known that pars plana vitrectomy commonly results in cataract development, especially in eyes in which an internal tamponade is performed.1-3 In many patients, cataract and vitreoretinal pathology are addressed in 2 separate procedures. However, there are several advantages offered by the combination of phacoemulsification and vitrectomy into 1 procedure, known as phaco-vitrectomy. The primary advantages of this combined approach include the elimination of a second procedure, improved access to the retinal periphery during phacoemulsification, and, in my opinion, better vitrectomy results.

Of course, there are also disadvantages associated with phaco-vitrectomy, including a less predictable refractive outcome, which is relevant in eyes with macula-off retinal detachments. In addition, phacoemulsification may be more difficult when the red reflex is missing, as in eyes with vitreous hemorrhage, for example. There is also a larger amount of debris on the intraocular lens (IOL), especially when the patient is required to maintain specific positioning (such as after macular hole surgery), which may cause decentration of the IOL. This, in turn, may yield an increased rate of posterior capsular opacification (PCO) development.

In an ideal situation, the anterior capsule is in front of the optic; however, very often in vitrectomy patients, we see a situation in which the anterior capsule is behind the optic, causing early PCO. In most cases, this occurs due to pressure from gas or air tamponade. At the end of surgery, the eye is filled with gas; once the patient gets up 2 to 3 hours after the procedure, the gas bubble creates its own force, which can cause the anterior capsule to move behind the optic.

PHACO-VITRECTOMY WITH THE TASSIGNON LENS

An IOL designed by Marie-José Tassignon, MD, PhD, FEBO, an anterior segment surgeon at Antwerp University Hospital in Edegem, Belgium, has proven effective in reducing the aforementioned complications. The bagin- the-lens (BIL) IOL, also known as the Tassignon lens (Morcher GmbH), is made of hydrophilic acrylic and has a 5-mm optic that is surrounded by a groove running 360° around the rim of the lens and elliptical haptics (Figure 1). The Tassignon lens requires both an anterior and a posterior capsulorrhexis, the edges of which are captured in the 360° groove. The anterior and posterior capsulorrhexes must each have a diameter of between 4.5 and 5 mm.

In the first step in my phaco-vitrectomy approach, a 23-gauge valved trocar (Dutch Ophthalmic Research Center) is inserted through the pars plana. This trocar will later be used for infusion to stabilize the intraocular pressure after phacoemulsification and to guarantee safe insertion of the other trocars for the vitrectomy instruments. Next, the anterior chamber is filled with high-viscosity sodium hyaluronate (Healon GV, Abbott Medical Optics), and a ring caliper is inserted through a 2.8-mm clear corneal incision into the anterior chamber and placed on the crystalline lens. This caliper serves as a guide for a 5-mm capsulorhexis.

The next step is standard phacoemulsification and removal of cortical material. The anterior chamber is then refilled with Healon GV; however, care must be taken not to inject the viscoelastic into the capsular bag but, rather, on top of the remaining peripheral anterior capsule only, so that the peripheral anterior capsule is pressed downward against the posterior capsule. Next, using a bent needle, a small tear is made in the center of the posterior capsule. A low-viscosity viscoelastic (Healon) is injected through this opening into the Berger space to detach the anterior hyaloid. Finally, the flap of the posterior capsule is grasped with forceps to perform a posterior capsulorhexis identical in size to the anterior capsulorhexis. The Tassignon lens is injected using a Naviject injector (Medicel AG) and is maneuvered into position, inserting both capsulorrhexes into the groove of the lens running 360° around the edge of the optic. During subsequent pars plana vitrectomy, the corneal wound is closed temporarily with 10-0 nylon suture.

RESULTS AND COMPLICATIONS

The Tassignon lens proved to be the IOL I had been looking for because it centered so nicely, regardless of the type of tamponade used. I have been performing phacovitrectomy using this lens now for 3.5 years and have completed more than 900 cases to date. Postoperatively, all of these cases look the same, and, in fact, some look better than my standard cataract cases without vitrectomy. Among these cases, I have treated patients with proliferative vitreoretinopathy, multiple vitreoretinal surgeries, and even uveitis or endophthalmitis.

One advantage of this technique is excellent centration of the Tassignon lens (Figure 2). The capsular bag closes immediately after surgery, meaning the 2 capsules seal in the area of lens epithelial cells.4,5 Therefore, the result is associated with much less glare in the anterior chamber during the postoperative period. However, the greatest advantage of phaco-vitrectomy with the Tassignon lens is that the iris has no chance to develop posterior synechiae, even in patients with diabetes, uveitis, or proliferative vitreoretinopathy (Figures 3–5).

Both intraoperative and postoperative problems are a possibility with this approach. Intraoperative problems may occur during phacoemulsification when there is pressure from behind. Therefore, it may be more beneficial to use local or topical anesthesia rather than peribulbar injections. Problems may also occur in eyes with missing red reflexes due to vitreous hemorrhage and in vitrectomized eyes due to the lack of counterpressure. Implantation may also be difficult in patients with small pupils and may require the use of iris hooks more often than in standard cataract surgery with a conventional lens.

In patients with vitreous hemorrhage, the red reflex may be blocked, hindering visualization during phacoemulsification. Therefore, I perform this technique not with the light of a microscope, but with the help of endoillumination placed in the anterior chamber. This enables the surgeon to achieve an excellent view of the posterior capsule. One disadvantage of using a separate light source is that it requires the surgeon to hold the phaco probe in 1 hand and the light in the other hand. When you believe the nucleus has been removed, put in the light and change the illumination technique to see how much cortical material is still in the eye, and then you can remove it.

CONCLUSION

Combined phaco-vitrectomy is an effective and safe technique. It is used routinely in all of our presbyopic patients. Whereas with intracapsular IOL implantation, complex pathologies can increase postoperative inflammation and result in posterior synechiae, the BIL lens guarantees excellent centration and never results in synechiae. Given these advantages, I would encourage readers to master the learning curve associated with phacovitrectomy and BIL implantation.

Claus Eckardt, MD, practices at the Augenklinik des Klinikum Frankfurt Hoechst, Frankfurt am Main, Germany. Prof. Eckardt states that he possesses patents for vitreoretinal instruments produced by Dutch Ophthalmic Research Center. He may be reached at +49 69 3106 2972; or via email at C.Eckardt@em.uni-frankfurt.de.

Dean Eliott, MD, is Associate Director of the Retina Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, and is a Retina Today Editorial Board member. He may be reached by phone: +1 617 573-3736; fax: +1 617 573 3698; or via email at dean_eliott@meei. harvard.edu.

Ingrid U. Scott, MD, MPH, is a Professor of Ophthalmology and Public Health Sciences, Penn State College of Medicine, Department of Ophthalmology, and is a Retina Today Editorial Board member. She may be reached by phone: +1 717 531 8783; fax: +1 717 531 5475; or via email at iscott@hmc.psu.edu.

  1. Hsuan JD, Brown NA, Bron AJ, Patel CK, Rosen PH. Posterior subcapsular and nuclear cataract after vitrectomy. J Cataract Refract Surg. 2001;27:443-444.
  2. Thompson JT. The role of patient age and intraocular gases in cataract progression following vitrectomy for macular holes and epiretinal membranes. Am J Ophthalmol. 2004;137:250-257.
  3. Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology. 1988;95:870-876.
  4. Tassignon MJ, De Groot V, Vrensen G. Bag-in the-lens implantation of intraocular lenses. J Cataract Refract Surg. 2002;28(7):1182-1188.
  5. De Groot V, Leysen I, Neuhann T, Gobin L, Tassignon MJ. One year follow-up of the “bag-in-the-lens” implantation in 60 eyes. J Cataract Refract Surg. 2006;32(10):1632-1637. Figure 5. Optical coherence tomography 3 months after combined phaco-vitrectomy. The 2 lens capsules (arrow) are located in the groove of the IOL.