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.