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Subspecialties Refractive, Cataract, Retina, Glaucoma, Glaucoma

Timing Is Everything

The optimal timing for the removal of retained lens fragments from the vitreous following complicated cataract surgery is controversial. Some retinal surgeons believe that removing the fragments on the day of cataract surgery is best, while others believe it is unnecessary to operate this quickly. Same day vitrectomy can interfere with the surgeon’s ability to obtain informed consent from the patient and could increase the rate of complications, and in cases where a retinal surgeon is not immediately available, it isn’t possible.

I believe the timing of retained lens fragment removal is time sensitive – just not in the way most physicians might think. Outcomes following retained lens fragment removal first appeared in the literature as the adoption of phacoemulsification became widespread (1). Results from the initial reports were somewhat disappointing but visual acuity (VA) results improved slowly over time (2). Some reports suggested that immediate vitrectomy appeared to reduce the risk of secondary glaucoma and retinal detachment (3), but superior VA improvements were inconsistent (4), and the discovery that medical management was possible in small, carefully selected groups of eyes only further complicated matters (5). The largest retrospective non-randomized cohort showed only a minimal trend to better vision following vitrectomy within the first week (6).

Faced with this inconsistent and conflicting data, we decided to dig deeper for answers by posing the following question: what does the entirety of the literature actually tell us? To answer this we performed a systematic literature review followed by a three-step statistical evaluation that included two meta-analyses. The first meta-analysis sought to determine the effects of delayed vitrectomy, and we found that early vitrectomy performed within three to 14 days after complicated cataract surgery decreased the risk of visual and anatomic complications (7). Mathematical modeling showed that the likelihood of patients remaining complication-free decreased with time to vitrectomy. But surprisingly, the review also suggested that performing a vitrectomy from days zero (same day as cataract surgery) to two resulted in worse vision – something that conflicted with our own experience.

We then analyzed our own 10-year data and found the opposite result - immediate vitrectomy resulted in improved long-term vision and less glaucoma progression (8) when compared to delayed vitrectomy. Finally, we performed a second meta-analysis that compared immediate vitrectomy with delayed vitrectomy, and determined that immediate vitrectomy is comparable to a three- to 14-day delay, but superior to a zero (but non-immediate) to two-day delay, and a 14+ day delay (9).

Our work, therefore, suggests that the optimal timing of vitrectomy for retained lens material is  bimodal – the best times are either immediately, or between days three and 14. So if immediate vitrectomy isn’t a viable option, all is not lost, as there is still time to achieve an optimal outcome.

The author reports no relevant financial disclosures.

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  1. DM Fastenberg et al., Am J Ophthalmol, 112, 535–9. (1991). PMID: 1951590.
  2. RR Margherio et al., 104, 1426–1432 (1997). PMID: 9307637.
  3. LJ Hansson, J Larsson, J Cataract Refract Surg, 28, 1007–1011 (2002). PMID: 12036645.
  4. IU Scott et al., Ophthalmology, 110, 1567–1572 (2003). PMID: 12917174.
  5. S Schaal, CC Barr, J Cataract Refract Surg, 35, 863–867 (2009). PMID: 19393885.
  6. YS Modi et al., Am J Ophthalmol, 156, 454–459 (2013). PMID: 23810473.
  7. EA Vanner, MW Stewart, Am J Ophthalmol, 152, 345–357 (2011). PMID: 21683330.
  8. EA Vanner et al., Clin Ophthalmol, 6, 1135–1148 (2012). PMID: 22888212.
  9. EA Vanner, MW Stewart, Clin Ophthalmol, 8, 2261–2276 (2014). PMID: 25429196.
About the Author
Michael Stewart

Michael Stewart is Professor and Chairman of Ophthalmology at the Mayo School of Medicine, Jacksonville, Florida, USA.

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