Klaus Lucke Bremen, Germany

There are many arguments why combined cataract surgery and vitrectomy should possibly be avoided. It constitutes more difficult surgery, there is an increased risk of peri-operative fibrin formation and then there is the fear of postoperative rubeosis iridis, neovascular glaucoma or keratopathy. As a result the older strategy in vitreoretinal surgery consisted of leaving the lens whenever possible and removing it totally via the pars-plana if it got in the way.
On the other hand there are quite a number of arguments for the combined approach: removing the lens first provides clearer optics intraoperatively, better access to the vitreous base, better optics for diagnostics and therapy postoperatively, and by implanting an IOL at the same time, the increased functional demands by the patients are satisfied, whereby it saves them and their insurers an additional procedure. Today, therefore, in the days of small incision cataract surgery with minimal trauma induced by the lens procedure such combined operations are starting to become standard.
Since 1994 we have used such a combined approach in over 3000 eyes in virtually all vitreoretinal indications. We routinely perform a phakoemulsification through a scleral 3,5mm frown incision and implant a foldable acrylic IOL in the bag before continuing with the vitreoretinal part of the operation. This has allowed us to be very thorough in cleaning the vitreous base which is indispensable for macular rotation procedures and we believe that by this we have also been able to reduce our late detachment rate after vitrectomies.
Rubeosis iridis has not been a factor. Of 193 diabetic vitrectomies in the year 2000 we used the combined approach in 79% (152 eyes) and found that thanks to extensive endolasercoagulation no eye developed rubeosis postoperatively. In diabetics, therefore, we are happy to choose the combined approach in all but a few eyes with florid anterior segment neovascularization. Active fundus proliferations constitute no contraindication.
In macular hole surgery long-acting gases inevitably cause a cataract in all cases. In the year 2000 we therefore used the combined approach in 109 of 111 phakic eyes. Complications related to the cataract part were limited to 6 eyes with a postoperative iris capture that could be resolved by induced miosis and prone positioning.
In younger people we now remove all lenses with a significant cataract at the time of vitrectomy. In all patients over 50 we choose the combined approach if there is any evidence of cataract at slit lamp examination and if a patient is over 60 there is no point in leaving a lens at vitrectomy, it will inevitably develop a cataract postoperatively and is therefore removed in all cases.
There is no doubt that combined surgery constitutes more difficult surgery. In experienced hands, however, the risk of complications is minimal, whereas patients can enjoy the advantages of a more thorough vitrectomy, better postoperative optics with faster final functional rehabilitation and they are furthermore spared an additional operation.