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Cataract Surgery from the Viewpoint of a Vitreoretinal Surgeon

Klaus Lucke

Bremen, Germany

Effective communication between anterior and posterior segment surgeons is often sadly lacking. Cataract surgeons frequently operate without much thought as to the possible consequences of their approach for the posterior segment and posterior segment surgeons in many places still frequently perform a pars-plana lensectomy without considering the optical complications of their procedure.
The advances in instrumentation, machinery and surgical techniques, however, nowadays allow a common strategic approach that takes into consideration all aspects of the anterior and posterior anatomy as well as refraction and optics to the benefit of the patient.
An element of these considerations is the responsibility of the cataract surgeon for the posterior segment in the selection of his surgical technique and the IOL used. It is widely accepted that myopic eyes can develop specific problems in the posterior segment that should be born in mind during a cataract operation. In addition, however, it should not be forgotten that all other eyes can also develop problems in the posterior segment which then could require long term good visualization for adequate diagnostics and therapy. Diabetic retinopathies, macular holes, epimacular membranes and those forms of age-related macular degenerations that are now amenable to therapy are meanwhile much more common than retinal detachments. The creation of optimally clear optics not only for the central fundus but also into the extreme retinal periphery is from the viewpoint of the vitreoretinal specialist of major concern. It might sound self-evident, but a centered IOL with a large and clear optical axis without optically disturbing edges, without anterior capsule fibrosis and significant regenerative PCO is even in today's highly advanced cataract surgery not achieved in a disturbing number of cases. We find all too frequently that a laser treatment or a vitrectomy is hindered significantly or even rendered impossible by massive after-cataract formation or a decentered IOL.
The material of the IOL used is also of concern to the posterior segment surgeon. Apart from the well known fact that the material influences the development of after-cataract, it must furthermore be born in mind that the use of silicone IOLs may jeopardize the use of silicone oil at a later date. Even for eyes at little risk of developing a retinal detachment this in itself could be a factor that might render a macular relocation operation difficult or impossible many years later. Indeed, we have in the past advised the occasional patient with a good indication for macular rotation surgery against such a procedure due to unsatisfactory conditions in the anterior segment after IOL surgery. In such cases, one would have to resort to complete removal of lens and capsular bag, an avoidable and unnecessary additional traumatization of the anterior segment, that furthermore makes full visual rehabilitation more than difficult.
With the thought in mind that all eyes could some day develop a posterior segment problem which might then necessitate a vitreoretinal procedure, our request to all cataract surgeons is therefore:
Always consider the long term optical result during every cataract operation. Please use small incision surgery and implant a large foldable IOL that centers well in the capsular bag, induces minimal fibrosis and PCO, which furthermore is compatible with silicone oil and has slender haptics that will allow visualization of the peripheral retina