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Combined versus Sequential Phacoemulsification and Pars Plana Vitrectomy

A Meta-Analysis
Published:January 19, 2021DOI:https://doi.org/10.1016/j.oret.2021.01.004

      Topic

      It is unclear whether differences exist in efficacy and safety between combined versus sequentially performed phacoemulsification and pars plana vitrectomy (phaco-PPV).

      Clinical Relevance

      This meta-analysis aimed to compare the efficacy and incidence of complications between these surgical methods.

      Methods

      Ovid MEDLINE, EMBASE, and Cochrane CENTRAL were searched for articles reporting the efficacy and safety of combined versus sequential phaco-PPV for any indication. The primary outcomes were postoperative best-corrected visual acuity (BCVA) and mean absolute refractive error from target (RET). Secondary outcomes included efficacy outcomes and postoperative complications. Meta-analysis was conducted using a random effects model in all cases. Risk of bias assessment was performed using the Cochrane risk of bias assessment tool for randomized trials and ROBINS-I tool for observational studies.

      Results

      Of the 5410 articles identified, 1 randomized controlled trial and 14 comparative studies were included, with 1407 and 951 eyes in the combined and sequential surgery groups, respectively. Mean age was 62.71 ± 6.16 years and 44% (range, 32.1%–70%) of eyes were from men. The mean baseline BCVA was 0.88 ± 0.59 logarithm of the minimum angle of resolution units (Snellen equivalent, 20/152). The meta-analysis showed no significance between groups in postoperative mean BCVA (P = 0.76) and mean absolute RET (P = 0.46). The risks of synechiae formation (risk ratio [RR], 2.74; 95% confidence interval [CI], 1.83–4.11; P < 0.001), fibrin formation (RR, 2.81; 95% CI, 1.84–4.30; P < 0.001), and intraoperative or postoperative retinal detachment (RR, 2.65; 95% CI, 1.08–6.47; P = 0.03) were significantly higher after combined surgery. However, the risks of posterior capsular tear (RR, 0.43; 95% CI, 0.25–0.73; P = 0.002) and macular hole nonclosure or reopening (RR, 0.18; 95% CI, 0.03–0.93; P = 0.04) were significantly lower in the combined group.

      Discussion

      No significant differences were found in visual and refractive outcomes between combined and sequential phaco-PPV, whereas differences existed in certain safety outcomes. These conclusions remain preliminary, as most evidence is derived from low- to moderate-quality retrospective studies. Given the variability in outcome reporting and associated heterogeneity, future randomized controlled trials are needed.

      Keywords

      Abbreviations and Acronyms:

      BCVA (best-corrected visual acuity), CI (confidence interval), D (diopter), ERM (epiretinal membrane), GRADE (Grading of Recommendations, Assessment, Development and Evaluation), IOP (intraocular pressure), MH (macular hole), PPV (pars plana vitrectomy), RCT (randomized controlled trial), RD (retinal detachment), RR (risk ratio), VH (vitreous hemorrhage)
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      References

        • Melberg N.S.
        • Thomas M.A.
        Nuclear sclerotic cataract after vitrectomy in patients younger than 50 years of age.
        Ophthalmology. 1995; 102: 1466-1471
        • Jackson T.L.
        • Donachie P.H.J.
        • Sparrow J.M.
        • Johnston R.L.
        United Kingdom National Ophthalmology Database Study of Vitreoretinal Surgery: report 1. Case mix, complications, and cataract.
        Eye (Basingstoke). 2013; 27: 644-651
        • Federman J.L.
        • Schubert H.D.
        Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery.
        Ophthalmology. 1988; 95: 870-876
        • Blodi B.A.
        • Paluska S.A.
        Cataract after vitrectomy in young patients.
        Ophthalmology. 1997; 104: 1092-1095
        • Feng H.
        • Aadelman R.A.
        Cataract formation following vitreoretinal procedures.
        Clin Ophthalmol. 2014; 8: 1957-1965
        • Beebe D.C.
        • Shui Y.B.
        • Siegfried C.J.
        • et al.
        Preserve the (intraocular) environment: the importance of maintaining normal oxygen gradients in the eye.
        Jpn J Ophthalmol. 2014; 58: 225-231
        • Koening S.B.
        • Han D.P.
        • Mieler W.F.
        • Abrams G.W.
        • Jaffe G.J.
        • Burton T.C.
        Combined phacoemulsification and pars plana vitrectomy.
        Archives of Ophthalmology. 1990; 108: 362-364
        • Lahey J.M.
        • Francis R.R.
        • Kearney J.J.
        Combining phacoemulsification with pars plana vitrectomy in patients with proliferative diabetic retinopathy: a series of 223 cases.
        Ophthalmology. 2003; 110: 1335-1339
        • Muselier A.
        • Dugas B.
        • Burelle X.
        • et al.
        Macular hole surgery and cataract extraction: combined vs consecutive surgery.
        Am J Ophthalmol. 2010; 150: 387-391
        • Chang M.A.
        • Parides M.K.
        • Chang S.
        • Braunstein R.E.
        Outcome of phacoemulsification after pars plana vitrectomy.
        Ophthalmology. 2002; 109: 948-954
        • Lee J.Y.
        • Kim K.H.
        • Shin K.H.
        • et al.
        Comparison of intraoperative complications of phacoemulsification between sequential and combined procedures of pars plana vitrectomy and cataract surgery.
        Retina. 2012; 32: 2026-2033
        • Treumer F.
        • Bunse A.
        • Rudolf M.
        • Roider J.
        Pars plana vitrectomy, phacoemulsification and intraocular lens implantation. Comparison of clinical complications in a combined versus two-step surgical approach.
        Graefes Arch Clin Exp Ophthalmol. 2006; 244: 808-815
        • Tosi G.M.
        • Balestrazzi A.
        • Baiocchi S.
        • et al.
        Complex retinal detachment in phakic patients: previtrectomy phacoemulsification versus combined phacovitrectomy.
        Retina. 2017; 37: 630-636
        • Hamoudi H.
        • Correll Christensen U.
        • la Cour M.
        Epiretinal membrane surgery: an analysis of 2-step sequential- or combined phacovitrectomy surgery on refraction and macular anatomy in a prospective trial.
        Acta Ophthalmol. 2018; 96: 243-250
        • Roh J.H.
        • Sohn H.J.
        • Lee D.Y.
        • et al.
        Comparison of posterior capsular opacification between a combined procedure and a sequential procedure of pars plana vitrectomy and cataract surgery.
        Ophthalmologica. 2009; 224: 42-46
        • Yang Y.
        • Zhang J.
        • Yan H.
        Comparison of combined and sequential surgery for proliferative diabetic retinopathy: a single surgeon study.
        PLoS One. 2014; 9: 1-5
        • Erçalık N.Y.
        • Yenerel N.M.
        • Sanisoğlu H.A.
        • et al.
        Comparison of intra- and postoperative complications of phaco between sequential and combined procedures of 23-gauge vitrectomy and phaco.
        Saudi J Ophthalmol. 2017; 31: 238-242
        • Chung T.Y.
        • Chung H.
        • Lee J.H.
        Combined surgery and sequential surgery comprising phacoemulsification, pars plana vitrectomy, and intraocular lens implantation: comparison of clinical outcomes.
        J Cataract Refract Surg. 2002; 28: 2001-2005
        • Higgins J.P.T.
        • Savović J.
        • Page M.J.
        • et al.
        Assessing risk of bias in a randomized trial.
        in: Higgins J.P.T. Thomas J. Chandler J. Cochrane Handbook for Systematic Reviews of Interventions. version 6. Cochrane. 2019 (Available at) (Accessed July, 2020)
        • Sterne J.A.
        • Hernán M.A.
        • Reeves B.C.
        • et al.
        ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.
        BMJ. 2016; 355 (Online): 1-7
        • Guyatt G.
        • Oxman A.D.
        • Akl E.A.
        • et al.
        GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables.
        J Clin Epidemiol. 2011; 64: 383-394
        • Bhatnagar P.
        • Kaiser P.K.
        • Smith S.D.
        • et al.
        Reopening of previously closed macular holes after cataract extraction.
        Am J Ophthalmol. 2007; 144: 252-259
        • Kim Y.K.
        • Woo S.J.
        • Hyon J.Y.
        • et al.
        Refractive outcomes of combined phacovitrectomy and delayed cataract surgery in retinal detachment.
        Can J Ophthalmol. 2015; 50: 360-366
        • Moisseiev E.
        • Kinori M.
        • Moroz I.
        • et al.
        25-Gauge vitrectomy with epiretinal membrane and internal limiting membrane peeling in eyes with very good visual acuity.
        Curr Eye Res. 2016; 41: 1387-1392
        • Tranos P.G.
        • Allan B.
        • Balidis M.
        • et al.
        Comparison of postoperative refractive outcome in eyes undergoing combined phacovitrectomy vs cataract surgery following vitrectomy.
        Graefes Arch Clin Exp Ophthalmol. 2020; 258: 987-993
        • Senn P.
        • Schipper I.
        • Perren B.
        Combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation in the capsular bag: a comparison to vitrectomy and subsequent cataract surgery as a two-step procedure.
        Ophthalmic Surg Lasers. 1995; 26: 420-428
        • Dugas B.
        • Ouled-Moussa R.
        • Lafontaine P.O.
        • et al.
        Idiopathic epiretinal macular membrane and cataract extraction: combined versus consecutive surgery.
        Am J Ophthalmol. 2010; 149: 302-306
        • Colyer M.H.
        • Berinstein D.M.
        • Khan N.J.
        • et al.
        Same-day versus delayed vitrectomy with lensectomy for the management of retained lens fragments.
        Retina. 2011; 31: 1534-1540
        • Smiddy W.E.
        • Michels R.G.
        • Stark W.J.
        • Maumenee A.E.
        Cataract extraction after retinal detachment surgery.
        Ophthalmology. 1988; 95: 3-7
        • Paques M.
        • Massin P.
        • Blain P.
        • et al.
        Long-term incidence of reopening of macular holes.
        Ophthalmology. 2000; 107: 760-765
        • Seider M.I.
        • Michael Lahey J.
        • Fellenbaum P.S.
        Cost of phacovitrectomy versus vitrectomy and sequential phacoemulsification.
        Retina. 2014; 34: 1112-1115