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Endoscopy assisted vitrectomy ( eav) for lens /IOL dislocation.

Claude Boscher

Paris, France

Objective : to evaluate endoscopy assisted vitrectomy for prevention of retinal detachment after vitrectomy for lens/IOL dislocation.
Purpose : outcomes of capsular rupture during phacoemulsification involve 1) potential visualization problems during vitreoretinal surgery , through a damaged anterior segment 2) a wellknown risk of secondary retinal detachment with significant anterior PVR potential . Endoscopy allows 1) viewing on 360°,through non transparent media, without scleral indentation ( potentially problematic after recent cataract surgery) 2) viewing of the anterior " zonular " vitreous base , involved in anterior PVR .
Methods : retrospective interventional consecutive case series ; 79 eyes in 79 patients ( 45 males , 35 females ) , were operated between November 1993 and October 2001. 6 patients were lost to follow up , 3 patients deceased before 6 months of follow up .Altogether 70 eyes have been included . 51 eyes presented lens material dislocation (46 during cataract surgery , 5 spontaneously) , and 19 eyes , a secondary IOL dislocation (after Yag in 1 case , trauma in 1 case , after vitrectomy in 1 case). Capsular rupture was complicated by simultaneous expulsive hemorrage in 2 eyes . A fiber optics system endoscopic probe with incorporated laser channel and a peristaltic vitrectomy machine have been used . Anatomical and functional results have been collected among the referring ophthalmologists . Pars plana phakoemulsification was used to remove lens fragments in 11/51(22%) eyes , perfluorocarbon liquids in 28/51 (55%) eyes . IOL was sutured in the sulcus in 32/70 ( 46 % ) eyes .
Results : no retinal tear nor retinal detachment occured after vitrectomy with a follow up of 6 months to 8.5 years . Iatrogenic retinal tear occured intraoperatively in 2 eyes , at the beginning of the series , due to the use of the endoscopic probe in 1 case , to giant tear during pars plana phakoemulsification in 1 case , and were complicated by intraoperative retinal detachment and anterior PVR ;. Best corrected final visual acuity is superior or equal to 20/40 in 50 (71 %) eyes , superior or equal to 20/30 in 33 (47 %) eyes .
Conclusion : there was not a single case of retinal detachment after vitrectomy and high magnification endoscopic dissection of the 360° adherences between anterior vitreous cortex, posterior lens capsule and zonular system , cleansing of fibrin and blood trapped in the anterior zonular vitreous base . Endoscopic suppression of visualization problems facilitated the conditions of vitrectomy ( transparency of anterior segment , pars plana phakoemulsification , lens fragments /IOL localization , capsular lens anatomical integrity and subsequent choice of implantation , control of IOL sulcus suturing ) , eliminated the delays of reoperation . It makes obsolete the usually spread recommendation of not implanting at the time of capsular rupture to facilitate viewing during subsequent vitreoretinal surgery (psychological advantage , shortening of reoperation and sparing of corneal endothelium ) . Specific complications of the technique occured during the leaning curve period , in 1994 .