Good Things Come to Those Who Wait

Deciding on the timing of pars plana vitrectomy (PPV) to remove retained lens material following cataract surgery can be a balancing act. On one hand, the cataract surgeon and the patient may be expecting immediate results. On the other, we need to plan the removal of the retained lens fragments in a way that avoids potential complications and optimizes visual outcome. So how do you choose?

In my experience, it is usually not necessary to perform same-day vitrectomy, and it may be preferable to delay the procedure – but this can mean different things for different patients. The evidence supports choosing a time that is individualized, taking into account patient, surgical and ocular factors. Usually, this means waiting for the corneal edema to clear, which can be anytime from four or five days after cataract surgery to the next week or two. The good news is that the timing of PPV to remove lens fragments is not critical – and the literature shows this.

The largest retrospective case series study published to date (1) evaluated 569 eyes: 117 had same-day PPV, and the rest were delayed. The results showed that both groups had similar outcomes with regards to visual acuity and complication rates. A meta-analysis (2), performed by my colleague Michael Stewart, evaluated 23 papers that compared same-day versus delayed PPV; they found no association between clinical outcome and PPV timing. There are a whole host of studies that reach the conclusion that timing is not critical (3)(4)(5)(6)(7). Problems reported with same-day and immediate PPV include increased rates of surgical complications, such as choroidal hemorrhage, and corneal decompensation, which may affect visualization of lens pieces. In addition, there are practical issues, such as informed consent, transport to another OR or facility, and the risk that a retinal physician won’t be available.

There are some mixed results in the literature, but this is because many studies are retrospective, non-randomized, and have variations in the procedure and the surgeon. There’s often limited information available about complications that occurred during cataract surgery, which might ultimately be the cause of the final visual outcome.

It is critical to refer the patient promptly to a retinal surgeon, either on the day of the event or the following day; the retinal surgeon is best placed to assess whether there are any posterior complications that need to be addressed immediately – or if the PPV can wait. As for my advice to the retinal surgeon? I suggest that they anticipate a rise in IOP, corneal edema, inflammation/cystoid macular edema, and wound and lens instability, and prophylactically treat for high IOP and inflammation. Do a controlled assessment of complications, optimize your visualization, and obtain informed consent. By tailoring the timing to the patient, you have the best chances of achieving a good outcome.