Managing Concurrent Cataract and Vitreomacular Traction

Cataract surgery can be performed safely in eyes with vitreomacular traction (VMT), but not all eyes with VMT require vitrectomy, said Ananth Sastry MD.

As a retina specialist who sees many patients referred for clearance before cataract surgery, Dr Sastry encouraged cataract surgeons to include a macular OCT in their preoperative workup to avoid missing pathology that is invisible on clinical examination. He noted the question of how phacoemulsification affects VMT occurred to him when examining a patient with VMT who had been sent for evaluation by their cataract surgeon.

“It has been well described in the literature that cataract surgery can induce a posterior vitreous detachment (PVD). However, we found there was very scant evidence about what happens when phacoemulsification is performed in the context of VMT,” Dr Sastry said. “Ideally, the traction would release and there would be spontaneous restoration of the foveal contour. However, there is also the possibility that there would be aggressive pulling of the vitreous, leading to a full thickness macular hole.”

To investigate whether phacoemulsification affects the rate of VMT release and VMT-related complications, Dr Sastry and colleagues performed a single-centre retrospective cohort study including 310 eyes with concurrent VMT and cataract.¹ The study compared outcomes in eyes that underwent cataract surgery (phacoemulsification) versus a control group with no intervention.

“Fascinatingly, our results showed no significant difference in the rate of VMT release between the two groups, and counterintuitively, the time to VMT release was longer in the phacoemulsification group than in the eyes that were simply observed,” he said. “Similarly, there was no significant difference between the phacoemulsification and observed groups in the rate of VMT-related complications, but there was a longer time to complication development in the phacoemulsification group.”

Multivariable analyses identified age as a significant predictor of VMT release with the probability of release decreasing with increasing age, which was another counterintuitive finding, Dr Sastry remarked. In addition, eyes with a larger adhesion diameter had a lower probability of release versus those with a focal adhesion.

When to perform vitrectomy

Dr Sastry said the decision to perform vitrectomy in eyes with VMT requiring cataract surgery is relatively straightforward, as it is guided by whether the VMT is clinically significant.

“It is important to understand that not all VMT is created equal, and not all eyes with VMT are candidates for vitrectomy,” he said.

Illustrating his point, Dr Sastry presented three cases of patients with concurrent cataract and VMT representing different levels of retina involvement and symptomatic impact. The first case described a patient with a focal adhesion whose visual complaints were judged to be cataract related.

“It would be perfectly safe to consider cataract surgery alone in this patient and to expect that their focal adhesion would likely release spontaneously,” he said.

OCT in the second case showed VMT with a slightly increased adhesion diameter and the ‘cotton ball sign’ indicating involvement of deeper outer retinal layers. Dr Sastry said he would consider the patient’s visual complaints in such a case.

“A patient noticing metamorphopsia or scotoma might be a good candidate for combined surgery, but if the patient’s symptoms seem to be just cataract related, it would be perfectly reasonable to consider a staged procedure beginning with cataract surgery and then considering vitrectomy later as needed,” he explained.

The third case showed a patient with a more advanced VMT associated with subretinal fluid. Patients with this presentation will almost certainly be symptomatic from their VMT and may be considered for vitrectomy. The question then becomes, should the vitrectomy be performed at the time of phacoemulsification or using a staged approach?

Noting that a combined procedure is the standard of care for surgeons outside the United States, Dr Sastry said it has advantages in being cost effective and efficient and sparing patients from having two different surgeries.

“In our retrospective study, we found a 15% rate of VMT-related complications regardless of whether eyes had cataract surgery or were observed. Doing vitrectomy at the time of cataract surgery could lower that rate of VMT-related complications,” Dr Sastry suggested.

A downside of combining the two surgeries is that vitrectomy in VMT poses difficulties and risks. Inducing a PVD can be challenging, and the risk of creating a retinal break or macular hole intraoperatively increases, thereby shifting VMT-related risks from the postoperative period intraoperatively. Then, if a retinal break, retinal detachment, or macular hole occurs intraoperatively, patients may need a gas tamponade that could cause IOL dislocation through a fresh capsulorhexis.

Finally, Dr Sastry suggested surgeons should consider whether vitrectomy may be unnecessary in cases with a higher probability of spontaneous release.

“If we can risk-stratify patients to get a good sense of which patients are more likely to have spontaneous release, doing a vitrectomy in such patients may be unnecessary,” he said.

Dr Sastry presented at the 2026 ASCRS annual meeting in Washington, DC.

Ananth Sastry MD is an attending surgeon and faculty member of the vitreoretinal service at the Cleveland Clinic Cole Eye Institute and assistant professor of ophthalmology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, US. ananth.sastry@gmail.com or sastrya@ccf.org

1. Bala S, et al. Am J Ophthalmol, 2026; 283: 176–187.