Sir,
We read with interest the recent articles by Jalil et al1 and Rahman and Stephenson,2 describing good visual outcomes from combined phacoemulsification and pars plana vitrectomy. Posterior capsular opacification (PCO) is a common occurrence after phacovitrectomy and we note that the PCO rate in both papers was significant (5.8 and 8.3%, respectively). A previous study has estimated PCO incidence to be as high as 21.5% after phacovitrectomy.3
Primary surgical posterior capsulotomy at the time of phacovitrectomy prevents post-operative PCO and this has been our standard clinical practice for several years. In this technique, the capsulotomy is performed at the start of vitrectomy using the vitreous cutter, after the intraocular lens (IOL) is implanted into the capsular bag, and results in a circular, centred, 4-mm diameter capsular opening.4
Primary posterior capsulotomy ensures removal of the anterior vitreous and improves visualisation for intraoperative peeling of epiretinal or internal limiting membranes, and also improves the fundal view during the post-operative period. Primary capsulotomy with posterior optic buttonholing has been recently described but we have not found this to be necessary.5 In our series of more than 1500 patients, we have not encountered IOL dislocation into the vitreous or IOL de-centration. This technique can be routinely used when implanting monofocal, multifocal, or toric IOLs. Our audited results have shown no difference in refractive outcomes between phacovitrectomy (with primary posterior capsulotomy) and phacoemulsification surgery alone.
We do not implant silicone lenses, but would advocate caution when such IOLs are used in a situation where silicone oil may be required. Silicone oil adherence to silicone IOLs is a well-recognised phenomenon that is notoriously difficult to treat.6
The only disadvantage of primary posterior capsulotomy is that during fluid–air exchange, condensation on the posterior IOL surface can obscure the view of the posterior pole. In this circumstance, application of hydroxypropylmethylcellulose to the posterior lens surface will rapidly restore the fundal view.
References
Jalil A, Steeples L, Subramani S, Bindra MS, Dhawahir-Scala F, Patton N . Microincision cataract surgery combined with vitrectomy: a case series. Eye (Lond) 2014; 28 (4): 386–389.
Rahman R, Stephenson J . Early surgery for epiretinal membrane preserves more vision for patients. Eye (Lond) 2014; 28 (4): 410–414.
Wensheng L, Wu R, Wang X, Xu M, Sun G, Sun C . Clinical complications of combined phacoemulsification and vitrectomy for eyes with coexisting cataract and vitreoretinal diseases. Eur J Ophthalmol 2009; 19 (1): 37–45.
Sato S, Inoue M, Kobayashi S, Watanabe Y, Kadonosono K . Primary posterior capsulotomy using a 25-gauge vitreous cutter in vitrectomy combined with cataract surgery. J Cataract Refract Surg 2010; 36 (1): 2–5.
Shin JY, Kim SE, Byeon SH . Primary posterior capsulotomy and posterior optic buttonholing in eyes with phacovitrectomy and gas tamponade. Retina 2014; 34 (3): 610–615.
Apple DJ, Federman JL, Krolicki TJ, Sims JC, Kent DG, Hamburger HA et al. Irreversible silicone oil adhesion to silicone intraocular lenses. A clinicopathologic analysis. Ophthalmology 1996; 103 (10): 1555–1561 discussion 1561–1552.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Rights and permissions
About this article
Cite this article
Alexander, P., Luff, A. Primary surgical posterior capsulotomy during phacovitrectomy. Eye 29, 590 (2015). https://doi.org/10.1038/eye.2014.300
Published:
Issue Date:
DOI: https://doi.org/10.1038/eye.2014.300