Abstract
The lens must never be preserved if this risks the success of dealing with pathologies involving the retina and the ciliary body. The removal may be achieved via standard phacoemulsification or using vitrectomy techniques. The choice is determined by the demands of the individual case, not by the surgeon’s personal preference (“my favorite technique is…”). If lens particles are present in the vitreous, their removal must be done so that the risk to the retina is minimized.
If combined surgery is performed, IOL implantation almost always accompanies it – but the keyword is “almost”: in certain cases, it is preferable to delay it. Occasionally it is best to remove the entire capsule and restore the eye’s refractive power via less traditional methods.
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Notes
- 1.
The eye becomes soft by the time the procedure is completed, making the cannula insertion difficult.
- 2.
Such as shallow AC, floppy iris, constricting pupil, VH seeping anteriorly, silicone oil prolapsing.
- 3.
Use of the probe and entering the eye through the cannula, respectively.
- 4.
The cut-off age is ~55–60 years, but a lot of other factors (such as the intraocular pathologies and the type of equipment) also play a role.
- 5.
The probe would otherwise tend to push the lens away, putting undue stress on the zonules.
- 6.
This will occur much more often than during phaco since the internal lumen of the probe is much smaller.
- 7.
And the remnant of the posterior capsule.
- 8.
Luxation in toto or lens particles lost during in situ PPL. Lens subluxation is discussed in Sect. 63.6.
- 9.
This is why the vitreous must be removed first; otherwise, VR traction is unavoidable.
- 10.
Cortex; nucleus in young people.
- 11.
Ultrasound may be required (see below, Sect. 38.3).
- 12.
My setup is similar to that used in vitreous removal: the initial pressing down with the pedal results in aspiration/flow; further pressing will activate the ultrasound (turning of the foot not required, see Sect. 16.3).
- 13.
If you are using a machine (such as the EVA by DORC, Zuidland, the Netherlands) that allows 23 g phacofragmentation; if only a 20 g phacofragmentor can be used, it is best to use a separate incision for it and then suture this sclerotomy before the vitrectomy is completed.
- 14.
It may be impossible to preoperatively recognize that the posterior capsule is broken; it is very difficult to recognize intraoperatively that vitreous has prolapsed into the lens. The risk is aspirating anterior vitreous and exerting traction on the retinal periphery (see Sect. 63.6).
- 15.
The old adage that “the eye needs to be compartmentalized” is not true anymore.
- 16.
Once the question is definitely answered, an IOL may be implanted secondarily.
- 17.
Defined here as an IOL that is placed after the PPV has been completed, but in the same surgical session.
- 18.
Defined here as an IOL that is implanted in a separate procedure in the future.
- 19.
Remember, the default goal is not the implantation of an IOL in the bag. Instead, the aim is to restore the rest of the globe anatomy to the fullest possible. Long-term thinking is needed, which is why the capsules may have to be sacrificed or the IOL implantation foregone.
- 20.
Marfan syndrome, pseudoexfoliation, homocystinuria etc.
- 21.
So that you can grab as large a piece of the capsule as possible.
- 22.
Up to ~30 years; extra caution is in order, due to the strength of the zonules. The risk is that the ciliary processes may be damaged as the pull force is transmitted to them.
- 23.
Using an A constant of 116,5, not 115,4 (Holladay 2 or SRK/T formula).
- 24.
Not all surgeons do this; pupillary-block glaucoma is indeed rare. The iridectomy is, however, highly recommended if the flat surface of the lens is against the iris.
- 25.
The IOL is well centered; it is rather easy to inadvertently move the lens in the horizontal plane as the claws are to be fixed to the iris.
- 26.
It is not uncommon that the VH occurs postoperatively, but it is almost always small and requires no intervention.
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Kuhn, F. (2016). Combined Surgery. In: Vitreoretinal Surgery: Strategies and Tactics. Springer, Cham. https://doi.org/10.1007/978-3-319-19479-0_38
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