Vitrectomy beneficial with retained lens fragments

An immediate vitrectomy should be considered in patients with retained intravitreal fragments of the crystalline lens after complicated cataract surgery. Eyes that underwent immediate vitrectomy had better visual acuity and a lower retinal detachment rate than eyes that underwent delayed vitrectomy.

Key Points

Chicago-An immediate vitrectomy should be considered in patients with retained intravitreal fragments of the crystalline lens after complicated cataract surgery. Eyes that underwent immediate vitrectomy had better visual acuity (VA) than eyes that underwent delayed vitrectomy, according to Michael W. Stewart, MD, who reported his results at the American Society of Cataract and Refractive Surgery annual meeting.

"The first reports on retained crystalline lens fragments emerged in the literature in the early 1990s and found that from 50% to 67% of patients achieved subsequent visual acuities of 20/40 or better," said Dr. Stewart, who is affiliated with the Department of Ophthalmology, Mayo Clinic, Jacksonville, FL. "Later reports, early in the next decade, showed comparable visual acuity results, but these studies also emphasized the importance of the development of retinal detachments and glaucoma as adverse visual outcomes.

"Some authors proposed that immediate vitrectomy performed in these patients results in improved visual acuity.However, other large studies contradicted that thesis," Dr. Stewart said. "Other authors thought that immediate vitrectomy minimized the risk of the development of secondary glaucoma."

Three groups

Cases were divided into three groups. The first group included patients who underwent cataract surgery at an institution other than Mayo Clinic and were referred to Mayo Clinic for delayed vitrectomy. The second and third groups included patients who underwent cataract surgery at Mayo Clinic and who were treated with immediate (i.e., the same day as cataract surgery) vitrectomy and those treated with delayed (i.e., 1 day or more after cataract surgery) vitrectomy. The baseline patient data, the incidences of pseudoexfoliation and glaucoma, and the baseline IOP values were similar among the groups.

Those in the groups that underwent delayed vitrectomy had elevated IOP; these cases were managed successfully with topical medication, according to Dr. Stewart.

"The final results were good in both the immediate and delayed vitrectomy groups, but there were some differences worth discussing," Dr. Stewart said.

A total of 39 eyes (38 patients) were included. Importantly, only 5% of the patients who underwent an immediate vitrectomy had a retinal detachment compared with 11% in the delayed vitrectomy groups.

The eyes that underwent immediate vitrectomy had a mean final VA of 20/30; 85% of the patients had a final VA of 20/40 or better, he said.

Patients who underwent a delayed vitrectomy had an average VA of 20/57 and only 58% had 20/40 or better compared with patients who underwent immediate vitrectomy. This difference reached significance (p = 0.03).

The development of secondary glaucoma did not appear to be influenced by the timing of secondary vitrectomy.

"However, we found it interesting that those who had pre-existing glaucoma required fewer postoperative medications to control IOP," Dr. Stewart said.

Patients who underwent immediate vitrectomy had less subsequent visual field loss as measured by mean deviation and pattern specific deviation compared with those who underwent delayed vitrectomy. This resulted in significant differences (p = 0.02 and p = 0.035, respectively).

"We found that the immediate removal of lens fragments does appear to improve the final visual acuity," Dr. Stewart said. "The immediate removal of lens fragments leads to a lower rate of retinal detachment compared with patients who underwent a later vitrectomy.

"Delayed removal of lens fragments did not lead to the development of secondary glaucoma, and immediate removal of lens fragments appears to improve the management of pre-existing glaucoma," Dr. Stewart concluded.