PHACOVITRECTOMY INDICATIONS Patients with visually significant cataracts undergoing vitrectomy are candidates for phacovitrectomy. Even patients with mild degrees of lenticular change are suitable for this procedure, as this will negate the need for cataract surgery at a later date and provide excellent posterior pole visualization for the surgeon. A relative contraindication is a retina surgeon who is inexperienced in phacoemulsification, as prolonged phacoemulsification can lead to corneal edema and poor visualization of the retina during vitrectomy. However, with current machines, techniques, and viscoelastic devices, phacoemulsification with IOL implantation can be safely performed in 10 to 15 minutes without corneal decompensation. ADVANTAGES OF PHACOVITRECTOMY Benefits to the patient include the following: The patient avoids 2 trips to the OR and has a faster overall postoperative recovery course compared with undergoing 2 separate procedures at different dates; The patient saves money, as copayments are avoided for the second procedure; The patient saves time, as he or she does not need to make appointments to see an anterior segment surgeon for the cataract procedure; Those without health insurance or who otherwise pay out of pocket greatly benefit from the combined procedure; and Visual rehabilitation is faster. Benefits to the retina surgeon include the following: Thorough and safe shaving of the vitreous base is possible without fear of lenticular touch. A better view of the retina is afforded for delicate maneuvers such as internal limiting membrane peeling and for detection of small retinal breaks. There is less concern for posterior capsular rupture or lens drop, as there is the ability to address such issues immediately when they occur. Phacoemulsification is easier in a nonvitrectomized eye because: (1) after vitrectomy, cataracts tend to be harder; (2) the anterior chamber tends to fluctuate during phacoemulsification in a vitrectomized eye due to the absence of vitreous support, possibly leading to posterior capsule rents and dropped nuclear fragments. For these reasons anterior segment surgeons are not keen to operate on vitrectomized eyes. There are no scheduling mishaps causing the retina surgeon to have to wait for the cataract surgeon to begin the case. Most insurance companies reimburse 100% for the retina procedure and 50% for the phacoemulsification, which can be an increased source of revenue for the retina surgeon. The patient is happy with the retina surgeon’s results, rather than allowing the cataract surgeon to become the hero when he or she does the phacoemulsification at a later date. Many ophthalmic manufacturers offer combined packs for phacovitrectomy at almost the same rates as individual phaco packs. The US health care system also stands to benefit in terms of cost savings of millions of dollars if more phacovitrectomies are performed by the retina surgeon.3 DISADVANTAGES OF PHACOVITRECTOMY Despite the advantages listed above, several potential disadvantages must be considered. The retina surgeon may fear a loss of referrals from anterior segment colleagues; in our experience, however, it has been quite the opposite. As noted above, cataract surgeons like to avoid doing phacoemulsification in vitrectomized eyes due to the higher risk of complications, and they are happy to let us take care of their patients’ cataracts during the vitrectomy procedure. Referrals stop, however, when the retina surgeon starts doing primary cataract surgeries. Another potential disadvantage is that the retina surgeon must be experienced with phacoemulsification. There is also a slightly higher chance of anterior segment inflammation when phacovitrectomy is performed in eyes with diabetic tractional retinal detachment. In such cases, we prescribe steroid drops every 2 hours for the first week, rather than the usual 4 times daily. Source : retinatoday/2014/10/phacovitrectomy-for-the-retina-surgeon/
Posted on: Tue, 28 Oct 2014 15:30:10 +0000
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