4.5Combined Surgery or Cataract Surgery Separately?

Technically, aphakia provides the least difficulty for a VR surgeon: there is no lens to interfere with visualization or to protect when working in the anterior part of the vitreous cavity. Aphakia, though, is very rare today, which leaves the VR surgeon to face a patient who is either phakic or pseudophakic. Both conditions present their own challenges; these are listed in Table 4.1.

Performing cataract and VR surgery in one setting has multiple advantages and a few disadvantages and challenges; these are shown in Table 4.2.

A few strategic and tactical issues are discussed below; the rest are found in

Chap. 38.

Table 4.1 Phakia vs pseudophakia as a challenge to the VR surgeon

aOr true lens damage (not lens touch, see Sect. 25.2.3.1) is inadvertently caused by the surgeon. bWhich can be performed with the probe in a much more controlled fashion than with YAG laser (see Sect. 3.1).

cLens feathering, gas cataract etc. dBroken zonules, IOL instability etc.

ePhacodonesis because of weak/damage zonules; IOL damaged during YAG capsulectomy; chronic endophthalmitis etc.

aCataract surgery precedes the VR surgery unless indicated differently.

bI tried to avoid repeating the obvious counterpart of what is mentioned in the other column (e.g., combined surgery saves money, but the opposite statement is not listed among the disadvantages of staged surgery).

cPreempt this problem by doing the calculation prior to the PPV.

•Even if the surgeon’s plan calls for preserving the lens,18 it makes sense to do the IOL calculation preoperatively.

–The lens may be damaged during PPV, requiring removal that was not planned originally.19

18It needs to be emphasized that every patient undergoing PPV will eventually develop cataract.

19Intraoperative lens feathering (see Sect. 25.2.3.1), whether due to the long duration of surgery or lengthy/repeated air tamponade, rarely interferes with visualization to the extent that lens removal becomes necessary.

–Silicone oil may have to be used, whose presence can make IOL calculation somewhat uncertain, especially if the cataract is very dense.20 Cataract progression is usually faster when silicone oil is present; therefore, preemptive lens removal should be considered.

•If combined surgery is performed, it is recommended to place the infusion cannula first.

–Opening of the infusion is rarely necessary until after the completion of the cataract surgery.

•Lens removal may be very difficult in the absence of a red reflex (significant VH is present).

•I try to avoid hydrating the corneal incisions – this requires constructing the wounds so that they are self-sealing (see Sect. 39.1).

–If the tunnel incision is leaking, a single 10-0 nylon suture is used to close it (see Sect. 63.4). The suture is left in place for at least a couple of weeks.

•It is preferable to use an IOL with a large optic.

•Once the IOL has been placed and the wounds are leak-free, the infusion is opened, the two working sclerotomies are prepared, and a standard PPV is carried out.

–I always perform a capsulectomy in the pseudophakic eye (see Sect. 25.2.3.4).

4.6Is It Acceptable That Financial Decisions21 Override the Medical Ones?

It is a sad reality, but one that all surgeons must accept: the funds available for VR surgery are limited. How to select the patients for operation so that the greatest possible number of those needing VR surgery have access to, and benefit from, it is not easy. Below are a few thoughts (not absolute rules!) to help making the triaging decisions.22

•Emergencies should have priority; in this definition of the term, an RD is an emergency.

•One-eyed patients should have priority.

•Those with very poor prognosis should be left toward the end of the waiting list.

•Those with good prognosis should be moved up on the waiting list.23

•Those with a condition that progresses slowly24 or do not cause permanent early damage25 should be placed somewhere in the middle of the list. Obviously, these

20The LenStar (Haag-Streit AG, Koenitz, Switzerland) is able to provide rather accurate readings.

21These are not made by ophthalmologists but by insurance companies, administrators, politicians, lawyers, businessmen etc.

22This is an incomplete list; those who often do triaging will have much to add to it.

23This is against the typical rationale in triaging. However, in VR surgery, delay almost always results in a progressively worse outcome, and the progression can be rather rapid.

24For example, EMP.

25For example, ME.