Clear lens extraction prompts vitreoretinal
Ana Hildago-Simón MD, PhD
NICE - Vitreoretinal surgeon Didier Ducournau MD voiced strong words
of caution to anterior segment surgeons, particularly in relation
to clear lens extraction, in a presentation at the XX ESCRS Congress.
Speaking at a clinical research symposium, the French specialist
discussed the potential posterior segment complications of anterior
Dr Ducournau is the vice-president of the European Vitreoretinal
Society (EVRS), an organisation created only two years ago. Its
goal is to do for the posterior pole of the eye what the ESCRS is
doing for the anterior segment.
"Our aim is educational. We embrace all the different philosophies
and ways of thinking across Europe. Perhaps the main point of departure
from the ESCRS is that we are more focused on the basic clinical
findings and practical techniques related to the back of the eye,
which are less well known than cataract operations," he said.
The love-hate relationship between anterior and posterior poles
of the eye was the main theme of this year's EVRS conference. Some
of the main topics discussed included techniques to deal with dislocated
IOLs; combined phaco and posterior vitrectomy; choice of IOL; endophthalmitis;
and pseudophakic retinal detachment. The rare anterior complications
which can follow vitreoretinal surgery were also discussed.
Dr Ducournau reported that capsule ruptures during cataract surgery
were a hot topic at the EVRS meeting. The patients should be referred
to a posterior segment surgeon, after hermetically closing the cornea,
The first choice of the vitreoretinal surgeon would be to perform
a complete posterior vitrectomy and a phacoemulsification aspiration,
followed by lens implantation. A sulcus-supported IOL would be preferred
but there was no clear favourite type of lens among participants
at the Congress, he noted.
"Don't try to clean the anterior chamber with an anterior vitrectomy
hand piece. They inject water into the vitreous cavity and effectively
increase vitreous exit. To enlarge the incision is also a bad idea;
posterior pole surgeons require a leakage free eye to work on.
"In fact, the situation most difficult to resolve in such a
case would be a choroidal detachment caused by a hypotonia and increased
by an inflammatory response. Finally, don't insert an IOL; it only
makes things more difficult for the vitreoretinal surgeon who will
have to deal with that eye later," Dr Ducournau explained.
He noted that for combined procedures, the vitreoretinal surgeon's
preferred approach is to perform phacoemulsification through a 1.2
mm incision in order to have a self-sealing incision.
"Some of us like to work with the Open Phaco machine because
it allows both vitrectomy with flow control and phacoemulsification
through a small incision," he advised.
If the problem is a dislocated IOL, a complete pars plana vitrectomy
is necessary. The aim is to leave the capsular bag as intact as
possible. A new technique for removal of the displaced IOL was presented
at the EVRS Congress in Greece.
It consists of getting hold of the distal haptic of the lens first,
to take advantage of the haptic/body angles, then turning the lens
and pulling it through the pupil without further damage to the eye
A special forceps with a lever and a wheel is the recommended tool
for this procedure.
Dr Ducournau also made some recommendations regarding the choice
of IOL from the vitreoretinal point of view. Foldable IOLs to be
inserted through a small incision are preferable.
In a survey of vitreoretinal surgeons present at the EVRS Congress,
silicone was not chosen by any surgeons as a favourite lens material.
This is probably related to the condensation problems observed in
silicone IOLs when injecting silicone, but also when injecting gas,
Although it is true that most early post-cataract surgery complications
are limited by phacoemulsification, the technique is not free of
long-term complications, Dr Ducournau said.
He had particularly strong views on the practice of clear crystalline
lens extraction followed by multifocal IOL implantation as a treatment
"I strongly recommend you leave the natural lens in place unless
extraction is truly required. You need to consider posterior eye
complications and a severely increased risk of blindness for those
patients," he cautioned.
Dr Ducournau explained that the rate of pseudophakic retinal detachment
(PRD) has been stable in recent years, confirmed by some large studies.
Nonetheless, the general impression among anterior segment surgeons
that the rate of PRD has decreased is simply not true, he said.
One reason for this misconception, Dr Ducournau believes, relates
to narrow sub-specialisation of cataract surgeons which isolates
them from posterior segment problems. He noted that most cataract
surgeons only see a small percentage of the PRD cases when they
The second reason is the mean onset delay of four years and seven
months which is longer than previously thought.
With the increase in life expectancy of the population, this delay
has major implications but not necessarily for the surgeon who performed
the cataract operation.
He stressed that although the severity of retinal detachments (RD)
has not changed with the introduction of phacoemulsification, the
rate of failure of RD is clearly increased by capsulotomies.
The risk is doubled if Nd:YAG is performed within six months after
cataract extraction, and tripled if a capsulotomy is performed within
six months and RD also occurs within the first six thereafter.
"The faster the retinal detachment occurs after phacoemulsification
or Yag, the higher the failure risk and the effects are cumulative,"
For more information on the European Vitroretinal Society, visit
its web page at www.evrs.org